Initiating dissection to achieve the critical view of safety in minimally invasive cholecystectomy: A retrospective comparison of lower-end-first, Calot’s triangle-first and salvage approaches

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstone disease. Achieving the critical view of safety (CVS) - clearing the hepatocystic triangle, freeing the gall bladder's lower third and identifying only the cystic duct and artery - is essential to prevent vasculobiliary injury. The guidelines advocate CVS but do not specify where to initiate dissection. We compared two dissection strategies. PATIENTS AND METHODS: We retrospectively analysed 350 consecutive laparoscopic cholecystectomies for acute cholecystitis (2020-2021 and 2024-2025) performed by two surgeons at community hospitals. In Method 1, n = 100, the lower third of the gall bladder was mobilised before dissecting Calot's triangle; in Method 2, n = 150, the triangle was dissected first and the lower gall bladder was then mobilised. Cases with severely inflamed or 'frozen' anatomy were treated with domedown or subtotal cholecystectomy (Method 3 salvage/bailout, n = 100). The outcomes included attainment of CVS, bile duct injury (BDI) and post-operative bile leak. RESULTS: CVS was documented in all Method 1 and Method 2 procedures, but not in the salvage group. No BDIs occurred. Post-operative bile leak rates were 2% for Methods 1 and 2 and 9% for Method 3; all salvage cases had intraoperative spillage and 3% required conversion to open surgery. Differences in leakage between the two planned techniques were not statistically significant. CONCLUSIONS: Both lower-end-first and Calot's triangle-first dissection strategies reliably achieve the critical view and allow the safe completion of LC. When inflammation prevents these approaches, domedown or subtotal cholecystectomy provides a safe bailout, with no BDI risk.