Subtotal cholecystectomy is a planned exit, not a failure

When severe inflammation prevents the critical view of safety — the cystic duct and artery as the only two structures entering the gallbladder, with the lower part of the gallbladder cleared off the liver bed — the safer course is to stop dissecting in Calot's triangle. A subtotal cholecystectomy removes the free wall and stones and leaves the posterior wall or neck, either closed (reconstituting) or left open with a drain (fenestrating).

Decide on this before the anatomy becomes dangerous, not after a structure has been divided. A drain and a clear operation note make the post-operative course easier for everyone who sees the patient next.

• Do not divide any tubular structure until the critical view of safety is achieved and documented.
• If it cannot be achieved, convert to a subtotal cholecystectomy, a fundus-first approach or cholecystostomy rather than pushing on.
• Leave a drain after a subtotal cholecystectomy and watch for a bile leak.
• Write which type of subtotal was done and whether stones may remain, so the next team knows.
• Warn the patient that a later ERCP or further operation may be needed.

Why it matters

Bile duct injuries commonly follow continued dissection through inflamed anatomy in an effort to finish the operation.

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