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A thick-walled gallbladder six days into an attack. The infundibulum is tethered to the duodenum and the triangle will not open from the front, so the dissection starts low on the gallbladder wall and works towards the cystic plate before anything is clipped.

Chapter outline

• 01:32 — Identification of the cystic duct
• 06:45 — Managing inflammation
• 12:20 — Critical view of safety
• 18:10 — Intraoperative cholangiography
• 23:40 — Controlling bleeding

Teaching points

• Start the dissection on the gallbladder wall, not in the triangle.
• The cystic plate is the component of the critical view most often missing.
• A tense gallbladder is decompressed before traction, not after.
• Cholangiography answers the anatomy question the inflammation has obscured.

Course: The difficult laparoscopic cholecystectomy