Initiating dissection to achieve the critical view of safety in minimally invasive cholecystectomy: A retrospective comparison of lower-end-first, Calot's triangle-first and salvage approaches.

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstone disease. Achieving the critical view of safety (CVS) - clearing the hepatocystic triangle, freeing the gall bladder's lower third and identifying only the cystic duct and artery - is essential to prevent vasculobiliary injury. The guidelines advocate CVS but do not specify where to initiate dissection. We compared two dissection strategies.

PATIENTS AND

METHODS

We retrospectively analysed 350 consecutive laparoscopic cholecystectomies for acute cholecystitis (2020-2021 and 2024-2025) performed by two surgeons at community hospitals. In Method 1, n = 100, the lower third of the gall bladder was mobilised before dissecting Calot's triangle; in Method 2, n = 150, the triangle was dissected first and the lower gall bladder was then mobilised. Cases with severely inflamed or 'frozen' anatomy were treated with domedown or subtotal cholecystectomy (Method 3 salvage/bailout, n = 100). The outcomes included attainment of CVS, bile duct injury (BDI) and post-operative bile leak.

RESULTS

CVS was documented in all Method 1 and Method 2 procedures, but not in the salvage group. No BDIs occurred. Post-operative bile leak rates were 2% for Methods 1 and 2 and 9% for Method 3; all salvage cases had intraoperative spillage and 3% required conversion to open surgery. Differences in leakage between the two planned techniques were not statistically significant.

CONCLUSIONS

Both lower-end-first and Calot's triangle-first dissection strategies reliably achieve the critical view and allow the safe completion of LC. When inflammation prevents these approaches, domedown or subtotal cholecystectomy provides a safe bailout, with no BDI risk.