The CVS technique, which was first described by Strasberg et al. in 1995, was introduced to reduce the risk of bile duct injury. A recent Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) expert Delphi consensus deemed the CVS as being the most important factor for overall safety.

Nowadays, the CVS technique is the gold standard to perform a safe cholecystectomy with identification of the vital structures such as the cystic duct.The reviewed literature suggests that judicious establishment of CVS could decrease bile duct injury rate, from an average 0.4% to nearly 0%.

To establish CVS, two windows need to be created during dissection of Calot’s triangle: one window between the cystic artery, cystic duct, and gallbladder, and another one between the cystic artery, gallbladder, and liver. The CVS technique is aimed especially at mobilizing the gallbladder neck from the liver in the appropriate cystic plate to obtain a circumferential identification of the cystic duct and its transition into the gallbladder.

The guiding structure for dissection should be the wall of the gallbladder. Proper retraction of the fundus cephalad and of the infundibulum posteriorly and laterally is necessary, and tenting by excessive lateral pulling on the gallbladder should be avoided. Cephalad traction on the fundus compresses Calot’s triangle, while lateral traction on Hartmann’s pouch tents up the CBD, which may then be mistaken for the cystic duct, especially when that duct is very short. The cystic duct should be dissected in a retrograde fashion, starting at gallbladder proceeding with the identification of the cystic duct–gallbladder junction on both sides and the visualization of the cystic duct–common bile duct junction prior to clipping.

Calot’s triangle should be dissected from all fibrous and fatty tissues. At the end of the dissection, only the cystic duct and artery cystica should enter the gallbladder and the bottom of the liver bed should be visible. The CBD is not necessary to be exposed. Failure to achieve the CVS is an absolute indication for conversion or additional bile duct imaging. The CVS should be described in the operative report.

Connor et al. and Wakabayashi et al. elegantly describe five key initial steps in performing safe laparoscopic cholecystectomy: (1) retract the gallbladder laterally to a 10 o’clock position relative to the principle plane of the liver (Cantlie’s line); (2) confirm Hartmann’s pouch is retracted up and towards segment IV; (3) identify Rouviere’s sulcus which marks the level of the right posterior portal pedicle and is identifiable in >80% of the patients. An imaginary line (R4U) drawn along the sulcus and carried across to the base of segment IV shows the level ventral to which dissection is “safe” and dorsal to which it is not; (4) dissect the posterior peritoneum of the hepatobiliary or hepatocystic triangle; and (5) confirm the critical view is obtained.

Preventive strategies and safe surgery are of utmost importance to minimize BDI during laparoscopic cholecystectomy. Although many methods used in the prevention of BDI have demonstrated promising results, there is no consensus regarding a systematic reporting system of BDI. Currently, CVS seems to be the cornerstone for a safe laparoscopic cholecystectomy. In difficult cases, a sufficient attention to alternative techniques should be apprehended. In such cases, intraoperative imaging may delineate the biliary anatomy.