The critical view of safety is a stopping rule, not a description: the hepatocystic triangle cleared of fat and fibrous tissue, the lower third of the cystic plate exposed, and two and only two structures entering the gallbladder. Until all three are met, nothing is divided. Dissection that is going well produces the view; dissection that is not going well produces reasons to accept less of it.
Set the decision point before starting rather than at the moment of difficulty. A fixed interval — commonly quoted as around 30 minutes of failing to make progress in a severely inflamed gallbladder — converts an escalating dissection into a planned change of operation. The alternatives are all legitimate operations: subtotal fenestrating or reconstituting cholecystectomy, cholecystostomy, or conversion to open.
Subtotal cholecystectomy is not a failure and should not be recorded as one. The operation note should say which variant was done, what was left behind, and whether the cystic duct was closed from inside, because that determines what a subsequent bile leak means and how it is managed. A retained stone in a remnant is a manageable problem; a divided common bile duct is not.
- Divide nothing until all three elements of the critical view of safety are demonstrated
- Agree a time or progress limit before the operation, so the decision to change course is not made under pressure
- Treat subtotal fenestrating or reconstituting cholecystectomy as a planned alternative, not a rescue
- Record in the note which subtotal variant was performed and what remains, since it changes how a later bile leak is interpreted
- Where the view cannot be obtained and the patient is unfit, cholecystostomy and interval reassessment remain options
Why it matters
Bile duct injuries mostly happen in operations where the surgeon decided to continue rather than in operations that were always going to be hard.
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