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Phase
2: Dissecting the Cystic Duct and Artery
Once the field is exposed, the infundibulum is grasped with the lateral
most grasper and pulled laterally, further exposing the cystic artery
and cystic duct. Attention is focused on Calot's triangle, an arbitrary
anatomic triangle defined by the cystic artery above, the cystic duct
below and the common bile duct medially. The operating surgeon then
inserts a dissecting instrument through the subxiphoid cannula and
identifies the cystic duct by teasing away the peritoneal covering of
the cystic duct-gallbladder junction. In acute cholecystitis, edematous
layers of tissue will have to be stripped downward to expose the cystic
duct. Dissection should continue in a lateral to medial direction,
beginning at the infundibulum and continuing medially toward the
entrance of the cystic duct into the gallbladder neck. In cases of
severe inflammation, this step can be tedious but must be performed with
extreme care to avoid damage to key structures such as CBD, right
hepatic artery, and duodenum. Once the junction between the cystic duct
and gallbladder neck has been identified, the cystic duct is dissected
circumferentially near the junction. A view demonstrating an empty space
between the liver and gallbladder neck, with the intervening cystic duct
in between, sometimes called the critical view, is desirable for reasons
of safety. In most cases, the cystic duct is anterior to the artery.
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