Before clipping or dividing anything in a cholecystectomy, achieve the critical view of safety: the hepatocystic triangle cleared of fat and fibrous tissue, the lower third of the gallbladder separated from the liver bed, and only two structures entering the gallbladder.
When inflammation prevents this, stop dissecting in the danger zone and choose a bailout — subtotal cholecystectomy, a fundus-first approach, cholecystostomy or conversion. A bailout is the safe operation, not a failure.
- Confirm all three elements of the critical view of safety before clipping.
- Photograph or record the critical view in the operation note.
- Choose a bailout when the view cannot be achieved, rather than pressing on.
- Call a second consultant early in a difficult gallbladder.
Why it matters
Most bile duct injuries come from misidentification, which the critical view exists to prevent.
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