Bile duct injury in cholecystectomy is most often a misidentification error, and the critical view of safety is the established check against it. Three criteria must be met before any structure is clipped or divided: the hepatocystic triangle is cleared of fat and fibrous tissue; the lower third of the gallbladder is separated from the liver bed to expose the cystic plate; and only two structures, the cystic duct and cystic artery, are seen entering the gallbladder. Confirm it from both the anterior and posterior views. When inflammation makes it unattainable, bail-out options such as subtotal cholecystectomy are safer than pressing on.
- Clear the hepatocystic triangle of fat and fibrous tissue.
- Separate the lower third of the gallbladder from the cystic plate.
- See only two structures entering the gallbladder before clipping.
- Photograph or record the view, and use a bail-out procedure if it cannot be achieved.
Why it matters
Most bile duct injuries happen when a surgeon is sure of the anatomy without having proved it.
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