When inflammation hides Calot's triangle and the critical view of safety cannot be reached, continuing to dissect is how bile duct injuries happen. Subtotal cholecystectomy removes the free gallbladder wall and leaves the part stuck to vital structures. The fenestrating form leaves the stump open and drained; the reconstituting form closes it.
Decide on bail-out criteria before the operation, not when frustrated at the end of it. Fenestrating repairs are more often followed by a bile leak, and reconstituting repairs leave a remnant that can form stones later.
- Stop and consider a bail-out if the critical view of safety is not reached after reasonable dissection.
- Remove all stones from the remnant and record which subtotal technique was used.
- Leave a drain after a fenestrating subtotal, and warn the patient about a possible bile leak.
- Tell the patient that symptoms from a remnant gallbladder can recur years later.
Why it matters
Bile duct injury is among the most harmful complications in general surgery, and the bail-out ends blind dissection.
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