Assessing the effect of the critical view of safety criteria on simulated operative decision-making: a pilot study.

BACKGROUND: Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its impact on intraoperative decision-making among trainees is unclear. METHODS: General surgery interns (n = 10) viewed a training module on the CVS criteria and then independently reviewed 20 cholecystectomy videos lasting 1 min each edited at various points of CVS dissection to include examples of both adequate and inadequate dissections. Participants were asked to identify the following CVS criteria for each video-(1) clearance of fat from the hepatocystic triangle; (2) exposure of the cystic plate; and (3) two and only two structures entering the gallbladder-and then decide if the structures were safe to divide. RESULTS: Inter-rater agreement for each CVS criteria varied: (1) (k = 0.2510), (2) (k = 0.2771), and (3) (k = 0.4298) as did the decision to divide critical structures (k = 0.371). Individual mean rate of dividing structures ranged 5-50% and did not correlate with the total number of CVS criteria identified by each participant (Spearman's rho = 0.247, p = 0.492). Division of structures with incomplete CVS identification occurred in 15% of cases and was isolated to one participant in the majority of cases (88%). Among these cases, omission of the cystic plate dissection occurred in every instance. CONCLUSIONS: Identification of CVS criteria was not uniform with the least amount of agreement on adequate hepatocystic and cystic plate dissection. Individual variation also exists between identification of CVS criteria and likelihood to divide structures. Video-based assessments that include intraoperative decision-making can help assess individual perceptions of safe practices without the risk of harm to the patient.