A Simple Effective Method for Generation of

a Permanent Record of the Critical View of Safety

during Laparoscopic Cholecystectomy by
Intraoperative “Doublet” Photography
Dominic E Sanford, MD, Steven M Strasberg, MD, FACS

BACKGROUND: The Critical View of Safety (CVS) is an established method for identifying the cystic duct
during laparoscopic cholecystectomy. Its goal is to prevent misidentification of the bile ducts
and avoid biliary injury. However, a visual record of CVS is not usually made. Intraoperative
photography has the potential to record CVS and increase the safety of laparoscopic chole-
cystectomy. The objective of this study was to develop a simple and effective technique for
recording CVS during laparoscopic cholecystectomy.
STUDY DESIGN: Techniques for photographing and rating photographs of CVS were developed. Surgeons
were trained in methods of photographing both anterior and posterior views of CVS during
laparoscopic cholecystectomy. Independent observers scored these views individually and
together. The term doublet view was used when both anterior and posterior views of CVS
were used for rating. Three criteria for CVS were used for scoring photographs. A total score
of
5 of 6 points was considered satisfactory, and a total score <5 of 6 points was considered
unsatisfactory.
RESULTS: Photographs of 28 patients were obtained. Critical View of Safety photographs were satisfac-
tory in either anterior or posterior single images in 43 of 56 (76.8%) instances, and doublet
photographs were satisfactory in 27 of 28 (96.4%) instances (p ¼ 0.02). Body mass index >40
predicted a higher likelihood of unsatisfactory individual CVS photos (p ¼ 0.02); however,
there was no correlation between patient or pathologic factors and the scores of doublet views.
CONCLUSIONS: With training and adherence to straightforward photographic techniques, intraoperative
doublet photography can record CVS accurately. This method is performed easily, and could
be used for recording of CVS in the medical record. (J Am Coll Surg 2014;218:170e178.

2014 by the American College of Surgeons)

The Critical View of Safety (CVS) is a method for identi-
fying the cystic duct and artery during laparoscopic chole-
cystectomy.1,2 Its goal is to prevent misidentification of the
common bile duct or aberrant ducts as the cystic duct and
avoid biliary injury. Several groups from the United States
and Europe have evaluated its use in thousands of patients
and have attested to its value in this regard.3-7 In none
of the patients in whom CVS was used did a bile duct
Disclosure Information: Nothing to disclose.
Received September 16, 2013; Revised November 2, 2013; Accepted
November 4, 2013.
From the Section of Hepato-Pancreato-Biliary Surgery, Department of
Surgery, Washington University in St Louis and Barnes-Jewish Hospital,
St Louis, MO.
Correspondence address: Steven M Strasberg, MD, FACS, Section of
Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington
University in St Louis, 4990 Children’s Pl, Suite 1160, Box 8109, St Louis,
MO 63110. email: strasbergs@wustl.edu
injury due to misidentification occur.3-7 A recent review
concluded that CVS should be considered the gold stan-
dard among operative techniques for assessment of biliary
anatomy during laparoscopic cholecystectomy.8 Yet,
despite the adoption of CVS as a mandatory step in lapa-
roscopic cholecystectomy by the Dutch Society of
Surgery,8 biliary injuries continue to occur at a considerable
rate in the Netherlands8 and elsewhere.9 Therefore, there
might be a difference between the use of CVS in the hands
of interested specialists3-7 and its value when used by
a broad range of surgeons, many of whom work in smaller
hospitals.8 A major problem in determining the reason for
this discrepancy is that, with the exception of the
Netherlands, there is usually no visual record that CVS
has actually been attained. This is unlike operative cholan-
giography, another method of identifying biliary anatomy,
in which images are routinely recorded.

ª 2014 by the American College of Surgeons ISSN 1072-7515/13/$36.00

Published by Elsevier Inc. 170 http://dx.doi.org/10.1016/j.jamcollsurg.2013.11.003
Vol. 218, No. 2, February 2014 Sanford and Strasberg
Table 1. Method for Taking Still Photographs of the Critical
View of Safety
1. Use 30-degree laparoscope.
2. White balance camera system.
3. Optimize lighting to reduce glare.
4. Dissect to the Critical View of Safety (CVS). Clean the cystic
structures so that they appear tubular and with little or no
extraneous material. The bottom one third of the cystic plate
should be visible. When rotating the bottom end of the gall-
bladder back and forth with a grasper to see the front and the
back of the hepatocystic triangle the CVS should be clearly
visible.
5. Position gallbladder and ducts with graspers to see dissected
hepatocystic triangle from an anterior view. Laparoscope should
be positioned so that the cystic duct and artery do not overlap.
There should be a clear view of the space between the back of the
cystic artery and the cystic plate so that the cystic plate is clearly
visible. A third grasper can be used to help position structures.
The 30-degree feature on the laparoscope can be used to provide
a view from the left that can enhance the separation of
structures.
6. The view on the screen should include enough of the gallbladder
to allow orientation. This usually means including the lower one
half of the gallbladder. Just before taking the picture, suction
field clean of blood and tissue fluid. Optimize focus.
7. Take anterior picture. Check pictures on inset on screen if
available to be sure that the 3 criteria for CVS have been
captured.
8. Re-position gallbladder to show the posterior view of the hep-
atocystic triangle. Rotate the laparoscope to optimize the view
from the right to attain maximal separation of structures as
above. Take posterior picture.
Dutch surgeons have led the way in determining the best
methods for recording CVS.10-14 They have evaluated oper-
ative notes, still photographs, and video recordings and
concluded that video recordings are the best of the 3
approaches. We too found that short videos seemed to
be a better way to evaluate whether CVS has been attained
than still photographs in a study on single-incision chole-
cystectomy.10 However, video recordings are more expen-
sive and logistically difficult to store than still photographs.
Therefore, creating and storing a visual record of CVS
would be facilitated by a method that was simple and inex-
pensive. In addition, although video recordings of CVS are
likely to always be better than still photographs, there has
not been an attempt to optimize the technique for photo-
graphing CVS to determine how effective still photos
might actually be for that purpose.
The aim of this study was to determine if use of
a simple standard technique for taking photographs of
CVS during laparoscopic cholecystectomy would result
in satisfactory recording of CVS. First, a standard method
of obtaining high-quality photographs was developed
along with a scoring system for assessing the photographs.
Photographing the Critical View of Safety 171
Then, surgeons who use CVS routinely were trained in
these photographic methods. They were asked to photo-
graph anterior and posterior views of CVS during laparo-
scopic cholecystectomies. Then, the anterior and
posterior views were presented separately and in combina-
tion (doublet view) to 2 raters who scored how effectively
the still photographs captured CVS.
METHODS
Standard methodology for obtaining still
photographs of the Critical View of Safety
Intraoperative laparoscopic photography is commonly
performed for teaching purposes and the ability to do
so is engineered into most modern laparoscopic camera
systems. We have gained experience in photographing
CVS for a number of years.10 In an earlier study, it
seemed much easier to make a judgment about CVS
when more than one still photograph was available for
review.10 For this reason, this study was designed to deter-
mine whether CVS was captured best by an anterior view,
a posterior view, or both views in combination, that is,
a “doublet” view. Based on our earlier study and subse-
quent attempts at photographing the CVS, a new tech-
nique for taking photos of the CVS was developed. The
8-step technique is described in detail in Table 1. Impor-
tantly, the operator should be sure that CVS can be seen
clearly from in front and behind by swinging the lower
end of the gallbladder back and forth before attempting
to take photographs. The common hepatic duct and
common bile duct do not need to be seen. To obtain
context, the whole hepatocystic triangle and the lower
one half of the gallbladder should be in the frame of
the photograph. Anterior and posterior views are taken.
Also, a list of common problems encountered when
taking photos was compiled and example pictures illus-
trating these avoidable problems were obtained (Fig. 1).
Study procedure
Seven surgeons in the sections of Hepato-Pancreato-Biliary
Surgery and Minimally Invasive Surgery in our institution,
who regularly perform laparoscopic cholecystectomy at
a rate >10 cases per year, were the subjects of the study.
All of these surgeons use CVS for anatomical identification.
The study was approved by our institutional IRB, and both
patients and surgeons were consented. No surgeon who was
approached refused to participate. Surgeons were briefed
on the purpose of the trial. They were then trained in the
methods described here (Table 1) and shown examples of
good and poor photographs (Fig. 1) at a conference
convened for this purpose or instructed individually.
Surgeons were also provided with a primer for taking
172 Sanford and Strasberg Photographing the Critical View of Safety
Figure 1. Common problems encountered when taking photographs of the Critical View of Safety. (A) Poor focus, (B)
too dark, (C) too bright, (D) too far, (E) too close, perspective lost, and (F) instrument obscures view.
photographs of the CVS with examples of desirable and
undesirable features. The primer is included as Supple-
mental Materials to the online version of this article (avail-
able at: http://www.journalacs.org) and contains Table 1
and pictures from Figure 1 as well as other information.
The rating system described here was also explained to
the participating surgeons so that they were aware of how
still photos taken by them would be scored by the referees.
Photographs were obtained at elective laparoscopic
cholecystectomy once the surgeon had displayed the
CVS. Anterior and posterior views were obtained using
the described methods and stored electronically. Surgeons
used either Karl Storz HD H3-Z or Stryker 1288 HD 3-
Chip laparoscopic cameras to obtain photographs during
the study. Photographs made by individual surgeons were
scored periodically to determine when surgeons reached
a “plateau” in their score on the doublet view. A plateau
was declared when 4 consecutive scores differed by 1 point
or less in the rating system. Once a plateau was reached,
that surgeon was considered to have completed the study.
Participating patients were patients of any age under-
going laparoscopic cholecystectomy who were willing to
be involved in the study and were patients of participating
surgeons. In this study protocol, photographs were not to
be taken in cases in which CVS was not attained, for
example, due to conversion to open procedure, but the
cause of failure was recorded.
Rating of photographs
For the purposes of scoring, the raters were presented with
the anterior view of the CVS, the posterior view, and the
J Am Coll Surg
doublet view, that is, both pictures at the same time. In
our earlier study, we used a scoring system based on the
3 criteria of CVS (ie, clear hepatocystic triangle; lower
part of gallbladder dissected off the cystic plate; and 2
and only 2 structures entering the gallbladder).10 In that
study, each of the criteria were noted either to be achieved
or not.10 However, it was thought at the time that a more
nuanced evaluation might be possible. For the purposes of
this study, a modified scoring system for the 3 criteria for
CVS was developed, the details of which are provided in
Table 2. In brief, 2 points were awarded for a criterion
when it was obvious immediately on viewing the photo-
graph that the criterion was fulfilled (Table 2). One point
was given when study of the photograph showed the crite-
rion was fulfilled, but the view was less than optimal. No
points were given for lesser results. The scores for each of
the 3 criteria were added. The range of possible scores
was from 0 to 6. Each photographic view (ie, anterior,
posterior, and doublet view) was rated. Doublets were
judged as a unit, and criteria could be satisfied either in
one or both images of the doublet to obtain the maximum
points. In other words, if 1 of the 3 requirements for CVS
was reached in only one view of a doublet, and the other 2
criteria were achieved only in the other view, a maximum
of 6 points would still be awarded. Therefore, for each
cholecystectomy performed, the photographs received 3
separate ratings for the anterior view, posterior view, and
doublet view.
The views were independently rated by 2 individuals,
a hepato-pancreato-biliary surgeon (SMS) and a research
fellow (DES), to obtain a mean score. A photograph was
Vol. 218, No. 2, February 2014 Sanford and Strasberg Photographing the Critical View of Safety 173

Table 2. Criteria for Judging Still Photographs of the Critical View of Safety
Two structures connected to the gallbladder
2 points Two structures can immediately and clearly be seen connecting to the gallbladder.
1 point Two structures can be seen connecting to the gallbladder, but there is some overlap of
duct and artery or a technical feature, such as poor lighting or lack of color contrast,
that interferes with clarity of determination. Photograph requires study to make
assessment.
0 points Due to overlap or technical issues 2 separated cystic structures cannot be seen.
Cystic plate
2 points Cystic plate is immediately clearly visible to approximately its bottom one third.
1 point Cystic plate is visible but overlapped by other structures so that it is not optimally seen or
an insufficient amount of the plate is shown. Photograph requires study to make
assessment.
0 points Cystic plate not visible due to positioning, light, obstruction of view by instruments, or
coverage with clot.
Clearance of hepatocystic triangle
2 points Hepatocystic triangle is cleared of tissue so that visibility of cystic structures and plate are
completely unimpeded, but also so that viewer can be immediately certain than no
other structures are in the triangle.
1 point Somewhat less than the whole triangle can be clearly seen or technical issues reduce ability
to see optimally. Photograph requires study to make assessment.
0 points Tissue in triangle obscures view of cystic structures cystic plate and does not allow
conclusion that that there are no other structures in triangle. Or technical issues prevent
determination of how well cleared the triangle is.

rated as demonstrating CVS satisfactorily when the mean
score of the 2 raters was 5.0, 5.5, or 6.0 points. Photos
with lower scores were considered to be unsatisfactory
photographs. The cut point between satisfactory and
unsatisfactory was high because an experienced partici-
pating surgeon had concluded that CVS had been
obtained and it should be confirmable by still
photographs if this method is to be considered reliable.
Statistical analysis
All data were analyzed using GraphPad Prism version
5.01 software. Calculating differences in numerical values
was conducted using unpaired t-test. Chi-square test was
used to compare categorical data. A p value <0.05
defined statistically significant differences.
RESULTS
The study ran from November 2012 to July 2013. Seven
surgeons and 31 patients participated. In 2 patients, there
were technical problems with the photographic equip-
ment, and in another the cystic artery was avulsed during
dissection. Twenty-eight patients were successfully photo-
graphed. Table 3 summarizes the study patients’ demo-
graphic and pathologic variables. It was expected that
between 5 and 10 procedures would be needed for
a surgeon to reach plateau (ie, 4 consecutive doublet
view scores that differed by 1 point or less), with a smaller
number for surgeons who had participated in our earlier
study. In fact, 3 surgeons completed the study in just 4
cases. Another surgeon completed 6 cases, all of which
are included in the analysis. In retrospect, this surgeon
had also reached plateau in 4 cases. Additional patients
were photographed because several cholecystectomies
were done within a very short period, and an interim
analysis was not possible after the first 4 cases were
completed. One surgeon reached plateau in 6 cases.
Two surgeons completed only 2 cases each after 6
months. They attained high scores on the doublet view
in all 4 cases. The trial was halted after 8 months because
the results were clear.
Figures 2 to 5 display examples of photographs that
obtained different ratings. In each case, the doublets are
displayed. Figure 2 and 3 demonstrate 2 cases in which
all 3 views (ie, anterior, posterior, and doublet) received
the maximum score of 6 points from both reviewers.
Table 3. Patient Demographic and Pathologic Variables
Characteristic
Age, y, mean (range) 51.6 (21e85)
Female, n (%) 13 (46.4)
Body mass index, mean (range) 35.4 (17e60)
Gallbladder wall thickness, mm, mean (range) 3.2 (1e10)
Cholelithiasis, n (%) 21 (75.0)
174 Sanford and Strasberg Photographing the Critical View of Safety J Am Coll Surg

Figure 2. Doublet photographs of the Critical View of Safety, which received maximum score of 6
points on all views. The complete clearance of the hepatocystic triangle, the presence of only 2
structures going into gallbladder and the lower one third of the cystic plate are visible immedi-
ately in both pictures.

Figure 4 is an example in which the doublet achieved 6
points, but the anterior and posterior views received
less. The anterior view (4.5 points mean score) did not
show the cystic plate well, and in the posterior view (5
points mean score) the separation of the cystic duct and
artery was less than ideal. However, both reviewers
concluded that examining both photographs simulta-
neously allowed determination that the criteria for cystic
plate visualization and 2 and only 2 structures entering
the gallbladder were well met when viewed as a doublet.
Figure 5 is an example of a poor photographic result. This
patient had scores of 3.5, 2.5, and 4.5 for anterior, poste-
rior, and doublet views, respectively, the worst results in
the study. In the anterior view, 2 structures entering the
gallbladder can be seen, but the cystic plate is obscured
and clearance of the hepatocystic triangle is uncertain.
In the posterior view, orientation is difficult. This patient
had a body mass index (BMI) of 52 and the gallbladder
appears to have been difficult to position. Also, there
might have been a problem with obtaining white balance,
as the picture is monochromatic. It should be emphasized
that there was no problem seeing the CVS by the surgeon
in real time during the operation. The problem was in
obtaining a satisfactory photograph of CVS.
Overall, 84 ratings were performed (28 anterior views,
28 posterior views, and 28 doublet views). The raters
were in agreement or within 1 point of agreement in the
0 to 6 scale in 81 of 84 ratings. In 3 instances, the reviewers
were 2 points apart. Two of these were ratings of the ante-
rior views and one in the posterior view. The individual
ratings were averaged to obtain the final scores. These are
shown in Figure 6 for the anterior, posterior, and doublet
views. Satisfactory ratings are shown in gray and unsatisfac-
tory ratings are displayed in black. The individual anterior

Figure 3. Doublet photographs of the Critical View of Safety (CVS), which received maximum
score of 6 points on all views. As for Figure 2, the 3 criteria of CVS are immediately visible in
both pictures. Note that although the cystic duct is thickened, one can be confident that the
structure is in fact the cystic duct.
Vol. 218, No. 2, February 2014 Sanford and Strasberg Photographing the Critical View of Safety 175

Figure 4. Doublet photographs in which the anterior view does not show the cystic plate well
(arrow) and the posterior view does not separate the cystic duct and artery well (circle). However,
in combination, the doublet received the maximum 6 points.

and posterior views received significantly lower ratings than
doublet views (5.21 vs 5.70; p ¼ 0.03). The posterior view
received lower rankings than the anterior view, but the
difference was not significant (5.05 vs 5.33; p ¼ 0.32).
Importantly, individual views were satisfactory in 43 of
56 (76.8%) instances, and doublet views were satisfactory
in 27 of 28 (96.4%) instances (p ¼ 0.02). In summary,
ratings were significantly higher when anterior and poste-
rior views were considered together by the rater at the
same time (doublet view) rather than when views were rated
individually and the doublet view almost always attained
a satisfactory rating.
A number of factors that might have affected outcomes
were examined, including age, sex, BMI, gallbladder wall
thickness, and presence of gall bladder inflammation on
pathology. Only BMI
40 had a significant negative
effect on the ratings of the individual views. Patients
with a BMI <40 were significantly more likely to have
a satisfactory rating on individual photographs compared
with patients with a BMI
40 (85.0% vs 56.3%; p ¼
0.02) (Fig. 7). However, there was no correlation between
patient demographic or pathologic factors, including
BMI, and the scores of doublet photographs. It is possible
that with larger numbers, additional influencing factors
might be detected in the future.
DISCUSSION
The Critical View of Safety as an effective method
to reduce biliary injury
Critical View of Safety was introduced as a method of
anatomical identification in laparoscopic cholecystec-
tomy in response to the reported high incidence of
biliary injury associated with that operation.1,2 Several
reports from expert centers involving >5,000 patients
indicate that the CVS method is effective in helping to

Figure 5. Example of unsatisfactory doublet photographs. The cystic duct is seen drawn to the
left and the cystic artery running over a curved dissector in the anterior view. However, the cystic
plate is obscured and clearance of the hepatocystic triangle is uncertain. Orientation in the
posterior view is difficult in the photograph, although the Critical View of Safety was clearly seen
in real time at surgery.
176 Sanford and Strasberg Photographing the Critical View of Safety J Am Coll Surg

Figure 6. Ratings for the anterior, posterior, and doublet views. Satisfactory ratings are shown in gray and unsat-
isfactory ratings are displayed in black. Individual views had significantly lower ratings than doublet views (5.21 vs
5.70; p ¼ 0.03) with about 25% of photographs falling into the unsatisfactory zone in individual views.

avoid misidentification injuries.3-7 Critical View of Safety

was made mandatory in the Netherlands 5 years ago, and
part of that mandate was that a visual record of CVS
should be obtained.11 However, there has not been
a measurable decrease in bile duct injuries in the
Netherlands. A recent registry report from Sweden
suggests that bile duct injury is still a common problem
in that country as well.9 There exists a seemingly contra-
dictory state with regard to the effectiveness of CVS.
Interested experts find that it is highly effective, but
when applied in a nationwide manner it seems to have
had little effect. Is this because the CVS method is truly
ineffective or because it is not being used correctly?
Without a method to record CVS accurately, this ques-
tion cannot be answered. The purpose of this study Figure 7. Compares the percent of satisfactory single Critical View
was to develop an accurate yet simple and inexpensive of Safety (CVS) images in patients with body mass index (BMI) <40
(gray bar; n ¼ 40) and
40 (black bar; n ¼ 16). Patients with BMI
way of recording CVS.
<40 were significantly more likely to have a satisfactory rating on
a single CVS photograph compared with patients with a BMI
40
Operative notes and The Critical View of Safety (85.0% vs 56.3%; p ¼ 0.02). However, there was no difference
Plaisier and colleagues and Wauben and colleagues found when using doublet views to rate photos.
that operative notes are a relatively poor method of deter-
mining whether CVS has been achieved compared with
a need for a simple, effective, and inexpensive way to
video recordings or still photographs.12-14 Our recent
record CVS visually during laparoscopic cholecystectomy
experience with referred biliary injuries is that although
to understand the pathogenesis and reduce the incidence
CVS is often mentioned in the operative report, a careful
of bile duct injuries.
reading often indicates that it could not have been
attained because one or more essential elements is missing.
Unfortunately, the “critical view” being described in these Dutch studies on visual recording of the Critical
operative notes is sometimes the view that is obtained View of Safety
when the so-called “infundibular technique”15 is used. Dutch surgeons have compared video recordings and still
In our opinion, this “funnel view” is an error trap and is photography, and concluded that the former is the supe-
associated with the occurrence of biliary injuries, espe- rior method of recording CVS accurately.12 However,
cially in the face of severe acute and chronic inflamma- videos are more expensive and difficult to store. More
tion.15 Because descriptions in operative notes are importantly, there has not been a systematic attempt to
missing or sometimes actually misleading, there is optimize techniques of still photography of CVS or to
Vol. 218, No. 2, February 2014 Sanford and Strasberg
instruct surgeons in these techniques. The study of Bud-
dingh and colleagues16 comes closest to our own, but
their results were very different from the results of this
study. They found that in almost half of the cases, still
photos were insufficient for determination of whether
the cystic duct had been identified confidently. However,
their study differed significantly in several ways. It was
retrospective, detailed teaching and a primer were not
available, doublet views were not specifically used for
rating, and the rating system was on a 1 to 10 scale
with less precise description of variables that made up
the score, that is, it was based on the “quality of the
images.” Also, their study used community surgeons as
subjects, and the current study used tertiary care
subspecialists.
Value of doublet photographs of the Critical View of
Safety
This study demonstrates that surgeons who are practiced
in dissecting to the CVS can obtain highly satisfactory
photographic images of the dissection displaying CVS.
The doublet view, which uses 2 images (ie, the anterior
and posterior views in combination) resulted in satisfac-
tory ratings in 27 of 28 procedures. These images would
be sufficient to conclude that the cystic duct had been
isolated and could be divided. The individual anterior
and posterior views received significantly lower ratings,
which were in the unsatisfactory range about 25% of
the time. Importantly, the improvement of scores in
the doublet is not simply due to selecting the best score
for each of the 3 attributes in the 2 pictures. Scanning
back and forth between views often leads to clarification
and increased confidence in what is being seen. For
instance, issues of overlap of the cystic duct and artery
with each other or with the cystic plate can often be
confidently resolved by scanning between the 2 views.
Had only one view been taken, the photo would have
been inadequate 25% of the time. The use of doublets
probably explains a lot of the difference between our
study and that of Buddingh and colleagues.16 It remains
to be seen whether the results of this study can be
achieved in a multi-institutional study involving hospi-
tals of different sizes.
CONCLUSIONS
With training and adherence to a straightforward photo-
graphic technique, an accurate recording of the CVS can
be made. Intraoperative doublet photography of CVS
during laparoscopic cholecystectomy is simple and easily
performed. This method could form the basis for
recording CVS, as is currently done for intraoperative
Photographing the Critical View of Safety 177
cholangiography and photographs of endoscopic proce-
dures. Recording in this manner might permit studies
to determine whether CVS is being attained, and will
allow for the evaluation of its efficacy in preventing biliary
injuries as well as provide insight into why these injuries
continue to occur.
Author Contributions
Study conception and design: Strasberg, Sanford
Acquisition of data: Sanford
Analysis and interpretation of data: Strasberg, Sanford
Drafting of manuscript: Strasberg, Sanford
Critical revision: Strasberg, Sanford
Acknowledgment: The authors express their gratitude to
the following surgeons who participated in this study:
Michael M Awad, L Michael Brunt, J Christopher Eagon,
Ryan C Fields, William G Hawkins, Daniel E Kleiner,
and David C Linehan.
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