Essential aspects to visualize and interpret the anatomy during a cholecystectomy:
1. Have the necessary instruments for the procedure, with adequate positioning of the trocars and a 30-degree optic.
2. Cephalic traction of the gallbladder fundus and lateral traction (pointing to the patient’s right shoulder), to reduce redundancy of the infundibulum.
3. Puncture and evacuation of the gallbladder to improve its retraction, in cases where traction cannot be performed easily (acute cholecystitis).
4. Lateral and caudal traction of the infundibulum, for correct exposure of Calot’s triangle, exposing the CD and artery.
5. “Critical view of Safety” to avoid misidentification of the bile ducts, ensuring that only two structures (CD and artery) are attached to the gallbladder. For this, they must be dissected separately, and the proximal third of the gallbladder must be moved from its fossa, to ensure that there is no anatomical variant there.
6. Systematic use of intraoperative cholangiography. Ideally by transcystic route or possibly by a puncture of the gallbladder.
7. Ligation of the cystic duct with knots (“endoloop”) to prevent migration of metallic clips that could condition a postoperative leak.
8. In case of severe inflammation of the gallbladder pedicle, with its retraction or lack of recognition of cystic structures, a subtotal cholecystectomy might be indicated.
9. In case of hemorrhage, avoid indiscriminate clip placement and or blind cautery. Opt for compressive maneuvers and, once the bleeding site has been identified, evaluate the best method of hemostasis.
10. If the surgeon is not able to resolve the injury caused, it is always better to ask for help from a colleague, and if necessary, to refer the patient to a specialized center.
The main goal in the postoperative management of BDI is to control sepsis in the first instance and to convert an uncontrolled biliary leak into a controlled external biliary fistula to achieve optimal local and systemic control. Definitive treatment to re-establish biliary continuity will be deferred once this primary goal is achieved and should not be obsessively pursued in the acute phase. The factors that will determine the initial presentation of a patient with a BDI in the postoperative stage are related to the time elapsed since the primary surgery, the type of injury, the mechanism of injury, and the overall general condition of the patient.