• Benjamin D Carr, Niki Matusko, Gurjit Sandhu, and Oliver A Varban.
• Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address: bdecarr@med.umich.edu.
• J Surg Educ. 2018 Nov 1; 75 (6): 1583-1588.

ObjectiveBile duct injury remains a serious complication of laparoscopic cholecystectomy despite established criteria for the critical view of safety (CVS). Using surgical videos, we compared surgeons' willingness to divide critical structures based on their assessment of the CVS dissection.DesignParticipants reviewed 20 operative videos lasting 1 minute each, edited at various points of the CVS dissection. Participants stated whether the structures were safe to divide, and if not, what steps they would take to achieve an adequate dissection. Videos were independently scored using a validated scale and categorized as an "adequate" or "inadequate" dissection based on the score. Participants were blinded to CVS score and adequacy. Cohen's kappa statistic was used to evaluate inter-rater agreement and responses were compared by univariate analysis.SettingUniversity of Michigan, Ann Arbor, Michigan. Tertiary care university hospital.ParticipantsGeneral surgery residents (n = 13) and faculty (n = 13) at the study institution.ResultsThere was minimal agreement on willingness to divide critical structures among all participants (κ = 0.25), among faculty (κ = 0.30), and among residents (κ = 0.21). Participants were more willing to divide critical structures when videos showed an adequate CVS dissection (CVS score ≥ 4) than an inadequate dissection (CVS score ≤ 3) (60.4% vs. 16.3%, p = 0.043). For inadequate dissections, participants most commonly recommended further dissection of the hepatocystic triangle (30.8%). There was no significant difference in the rate of unsafe practices (choosing to divide critical structures for videos with an "inadequate" dissection) between faculty and residents (14.2% vs. 18.3%, p = 0.781).ConclusionsThere was minimal agreement on what constituted a safe CVS dissection and there was no difference in the rate of unsafe practices between trainees and faculty. Education may play a more important role than experience when building a culture of safety for laparoscopic cholecystectomy.Copyright © 2018 Elsevier Ltd. All rights reserved.

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