Bile duct injury happens when the common bile duct is mistaken for the cystic duct. The critical view of safety prevents this: clear the hepatocystic triangle of fat and fibrous tissue, separate the lower third of the gallbladder from the liver bed, and see only two structures — the cystic duct and the cystic artery — entering the gallbladder. Confirm it from both the anterior and posterior views and record it, ideally with a photograph. If it cannot be achieved in an inflamed emergency gallbladder, stop dissecting in the triangle and choose a bailout: subtotal cholecystectomy, cholecystostomy, or help from a colleague.
- Achieve the critical view of safety before clipping or dividing any structure.
- Confirm exactly two structures entering the gallbladder, seen from both front and back.
- Photograph or describe the critical view in the operation note.
- If it cannot be achieved, use a bailout — subtotal cholecystectomy or cholecystostomy — rather than pressing on.
Why it matters
Whatever the platform, a disciplined critical view prevents more bile duct injuries than the choice of instrument.
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