In a hostile gallbladder with dense inflammation, the established advice is to stop pursuing the critical view of safety once it cannot be reached safely and to choose a bailout instead. A subtotal cholecystectomy removes the safely separable gallbladder and leaves the wall adherent to the hilum, which is a recognised way of avoiding bile duct injury.
Seek a second surgeon's view, consider conversion to open surgery and place a drain where leak is possible. Document the reasoning and tell the patient, since a bile leak or retained stones are possible afterwards.
- Stop and re-assess when the cystic duct and artery cannot be identified clearly.
- Consider subtotal cholecystectomy, a second opinion or conversion instead of pressing on.
- Drain where a bile leak is likely and watch for one afterwards.
- Record the reason for the bailout and discuss it with the patient.
Why it matters
Bile duct injury is the complication that follows a surgeon for years, and knowing when to stop prevents it.
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