3. Imaging. Make liberal use of cholangiography or other methods
to image the biliary tree intraoperatively. Cholangiography may be
especially important in difficult cases or unclear anatomy. Studies
have shown that cholangiography reduces the incidence and extent of
bile duct injury, but the subject remains controversial.
4. Time out. Take an intraoperative time out during a lap chole
before clipping, cutting or transecting any ductal structures. The time
out should consist of a stop point in the operation to confirm that
you've achieved the CVS.
5. Dangerous dissections. Recognize when the dissection is
approaching a zone of significant risk and halt the dissection before
entering the zone.
Finish the operation
by a safe method
other than cholecys-
tectomy if conditions
around the gallbladder
are too dangerous. In
situations where there
is severe inflammation
in the porta hepatis
and neck of the gall-
bladder, the CVS can
be difficult to achieve.
The fact that achieving
the CVS appears not
feasible is a key bene-
M A Y 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 5 5
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