Intraoperatively, a patient undergoing laparoscopic cholecystectomy is found to have the cystic artery arising directly from the right hepatic artery running in front of the common hepatic duct (caterpillar/Moynihan's hump variant). The single most important safety maneuver is:

• A Convert immediately to open surgery
• B Perform intraoperative cholangiography before any dissection
• C Divide the cystic duct first, then identify the artery
• D Achieve the critical view of safety (CVS) before any clipping or division ✓

Explanation

The critical view of safety (CVS), described by Strasberg, requires: (1) the hepatocystic triangle cleared of fat and fibrous tissue; (2) the lower third of the gallbladder separated from the liver bed; and (3) only two structures (cystic duct and cystic artery) entering the gallbladder. Achieving CVS before any division is the primary strategy to prevent bile duct injury regardless of anatomical variants. In cases where CVS cannot be confidently achieved, conversion or subtotal cholecystectomy is preferred over proceeding blindly.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.