During laparoscopic cholecystectomy, the 'critical view of safety' (CVS) is not achieved due to excessive inflammation. Which technique is recommended to minimize bile duct injury in this scenario?

• A Proceed with clipping and dividing the two structures visible in the triangle of Calot
• B Perform a fundus-first (top-down) cholecystectomy or subtotal cholecystectomy ✓
• C Convert to open cholecystectomy and use intraoperative cholangiography
• D Insert a choledochoscope to identify structures

Explanation

When the critical view of safety cannot be established, the recommended 'bail-out' procedures are fundus-first (retrograde) cholecystectomy, subtotal cholecystectomy (fenestrating or reconstituting type), or conversion to open surgery. The Tokyo Guidelines and SAGES guidelines classify these as acceptable safe alternatives. Proceeding to clip structures without CVS is the primary cause of major bile duct injuries. Subtotal cholecystectomy (leaving the posterior cystic plate intact when the hepatocystic triangle is frozen) is the safest option when dissection is unsafe. Intraoperative cholangiography may help identify anatomy but cannot replace safe dissection technique in severe inflammation.

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

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Written and medically reviewed by the StethoPrep medical team.