Cystic Artery Dissection With Dorsal Infundibular Approach Versus Critical View of Safety

Achievement of the Critical View of Safety (CVS) requires the completion of three mandatory criteria prior to the application of clips: first, the complete clearance of all fibro-fatty tissue from the hepatocystic triangle; second, the mobilization of the lower pole of the gallbladder from the liver bed to expose at least the inferior third of the cystic plate; and finally, the clear demonstration of exactly two structures-the cystic duct and cystic artery-entering the gallbladder. Only upon definitive visualization of these components is the CVS considered achieved

Following optimized gallbladder retraction and identification of the Rouviere's sulcus, any existing adhesions were cleared via a combination of blunt and sharp dissection. The procedure commenced with a peritoneal incision on the right lateral aspect at the cysto-infundibular junction, facilitating lateral retraction of the infundibulum and opening of the hepatocystic (Calot's) triangle. Subsequently, the left-sided peritoneum was incised along the anterior border of the cystic artery, extending over the inferior fourth of the gallbladder. Precise hemostasis was maintained, particularly at the ductal branches, to ensure a clear operative field. Connecting the bilateral peritoneal incisions ventrally facilitated the creation of a retro-ductal window. This maneuver allowed for superior retraction of the infundibulum away from the common bile duct, effectively straightening the cystic duct for safer identification