Intraoperative Difficulty, Rather Than Preoperative Factors, Determines Failure to Achieve the Critical View of Safety During Laparoscopic Cholecystectomy: A Large Cohort Study

Background: Failure to achieve the critical view of safety (CVS) during laparoscopic cholecystectomy is an uncommon but clinically significant intraoperative scenario that necessitates alternative strategies to prevent bile duct injury. Although preoperative models are widely used to predict difficult cholecystectomy, their ability to identify cases in which safe dissection becomes unachievable remains unclear. Methods: This retrospective cohort study included 1001 consecutive patients undergoing laparoscopic cholecystectomy. CVS failure was defined as the inability to safely complete standard dissection, requiring transition to a bailout strategy. Clinical, laboratory, imaging, and intraoperative variables, including the Nassar difficulty score, were analyzed. Independent predictors were assessed using Firth penalized logistic regression. Results: CVS failure occurred in 19 patients (1.9%), reflecting the rarity but clinical significance of this intraoperative endpoint. Patients with CVS failure had significantly higher Nassar scores and more frequently underwent emergency surgery. In multivariable analysis, intraoperative difficulty, as measured by the Nassar score, was the strongest independent predictor of CVS failure (OR=18.44, 95% CI: 7.79-62.67; P <0.001), whereas preoperative variables were not independently associated with CVS failure. Conclusion: Failure to achieve CVS is primarily driven by intraoperative difficulty rather than preoperative factors. These findings highlight CVS failure as a distinct intraoperative threshold and support the importance of structured intraoperative assessment to guide the timely adoption of bailout strategies and enhance surgical safety.