58 - CRITICAL VIEW OF SAFETY PLUS: IMPROVING THE SAFETY OF LAPAROSCOPIC CHOLECYSTECTOMY WITH INDOCYANINE GREEN DYE

Objectives: The critical view of safety is anterior and posterior visualization of the cystic duct and cystic artery with exposure of cystic plate. Indocyanine green (ICG) is used to visualize the biliary tract because of its excretion through the biliary system. Visualizing the biliary anatomy using ICG prior to clipping and incision allows for prevention of missed biliary anatomy; this could also reduce incidence of bile duct injury. We propose that the addition of ICG fluoroscopy with the critical view of safety be termed the critical view of safety plus. Operative photographs of critical view of safety and critical view of safety plus will be graded by a control surgeon to determine how critical view of safety plus scores compared to critical view of safety scores.

Methods: Fifty operative dissections were randomized, double-blinded, and assessed by a control surgeon comparing critical view of safety and critical view of safety plus using a standardized grading system. The critical view of safety is graded in white light, then the control surgeon is asked whether to complete the operation by choosing “cut”; if not describe what they would perform: isolate the cystic artery, isolate the cystic duct, or expose the cystic plate. The critical view of safety plus is assessed similarly.

Results: The decision to “cut” was chosen 29 (58%) when viewing the critical view of safety plus vs 22 (44%) with the critical view of safety (χ2=65.822, p< 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 (16%) vs 11 (22%) with critical view of safety (χ2=65.822, p< 0.0001). The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p=0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: “two structures connected to the gallbladder” (average 1.54 vs 1.50, p=0.598), “cystic plate clearance” (average 1.42 vs 1.28, p=0.018), and “hepatocystic triangle clearance” (average 1.4 vs 1.26, p=0.0334).

Conclusion: The critical view of safety plus increases efficiency and decreases perception illusion through improved visualization of the biliary tree, allowing for identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury.