University of Michigan Medical School, 2926 Taubman Center, 1500 E Medical Center Drive, SPC 5343, Ann Arbor, MI, 48109-5343, USA.
Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.
Surg Endosc. 2019 Mar;33(3):911-916. doi: 10.1007/s00464-018-6385-8. Epub 2018 Aug 22.
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.
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.
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.
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.
尽管腹腔镜胆囊切除术（LC）中确定关键安全视野（CVS）有既定标准，但它对实习生术中决策的影响尚不清楚。
普外科实习医生（n=10）观看了有关 CVS 标准的培训模块，然后独立查看了 20 个时长 1 分钟的 LC 视频剪辑，这些剪辑在 CVS 解剖的各个点进行编辑，包括充分和不充分解剖的示例。参与者被要求为每个视频确定以下 CVS 标准：（1）清除肝胆囊三角脂肪；（2）暴露胆囊壁；（3）两个且只有两个结构进入胆囊，然后决定这些结构是否可以安全分离。
每个 CVS 标准的观察者间一致性不同：（1）（k=0.2510），（2）（k=0.2771），（3）（k=0.4298），以及分离关键结构的决策（k=0.371）。个体平均分离结构的比例为 5-50%，与每个参与者识别的 CVS 标准总数无关（Spearman's rho=0.247，p=0.492）。在未充分识别 CVS 的情况下分离结构的情况发生在 15%的病例中，且大多数情况下仅发生在 1 名参与者中（88%）。在这些病例中，胆囊壁的解剖总是被遗漏。
CVS 标准的识别不一致，最一致的是充分的肝胆囊和胆囊壁解剖。个体对 CVS 标准的识别和分离结构的可能性之间也存在差异。基于视频的评估可以帮助评估个体对安全操作的看法，而不会对患者造成伤害的风险。
