Most bile duct injuries come from misidentifying the common bile duct as the cystic duct. The critical view of safety guards against this by requiring three things before any structure is clipped: the hepatocystic triangle cleared of fat and fibrous tissue, the lower third of the gallbladder separated from the liver bed, and exactly two structures entering the gallbladder.
When inflammation makes this impossible, the safer course is a bail-out — subtotal cholecystectomy, a fundus-first approach, or drainage — rather than pressing on.
- Confirm all three components before clipping, and pause to state them aloud.
- Photograph or record the view for the operation note.
- If the view cannot be achieved, move to a bail-out rather than continuing dissection.
- Call a second surgeon early in a hostile triangle.
Why it matters
Bile duct injury is rare but life-changing, and most cases come from a misread structure.
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