When the critical view of safety cannot be achieved in a severely inflamed gallbladder, continuing to dissect in Calot's triangle is where bile duct injuries happen. A subtotal cholecystectomy, fenestrating or reconstituting, removes most of the gallbladder and its stones while leaving the dangerous area alone.
It carries its own risks, chiefly bile leak and retained stones, so a drain and a follow-up plan are part of the procedure. Deciding on the exit early, and saying so aloud to the team, is safer than reaching it late after a long struggle.
- Stop and reassess if the critical view of safety is not achieved after reasonable dissection.
- Consider subtotal cholecystectomy, conversion or a cholecystostomy rather than pressing on.
- Leave a drain after subtotal cholecystectomy and plan follow-up for bile leak and retained stones.
- Document why a bailout was chosen; it is a safety decision, not a complication.
Why it matters
Bile duct injury is the complication that bailouts exist to prevent.
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