Structures Clipped During Laparoscopic Cholecystectomy
The correct answer is (a) Cystic artery & cystic duct—these are the only two structures that should be clipped and occluded during safe laparoscopic cholecystectomy. 1
The Critical View of Safety (CVS) Standard
The 2020 World Society of Emergency Surgery guidelines explicitly define proper technique through the CVS schema, which mandates visualization of only 2 structures entering the gallbladder: the cystic duct and the cystic artery before any clipping or transection occurs. 1
Key Technical Principles:
The hepatocystic triangle must be visualized with NO exposure of the common bile duct—this is a critical safety checkpoint to prevent catastrophic bile duct injury. 1
Only the cystic duct and cystic artery should be identified, isolated, clipped, and divided during standard laparoscopic cholecystectomy. 2, 3, 4
The gallbladder is then dissected from the liver bed after these two structures are secured, completing the procedure. 1, 3
Why Other Options Are Incorrect and Dangerous:
Option B (Common bile duct & cystic duct): Clipping the common bile duct represents a major bile duct injury (Strasberg E) requiring complex reconstruction with Roux-en-Y hepaticojejunostomy—this is a devastating complication, not proper technique. 1
Options C & D (Right hepatic artery structures): These involve major vascular structures that should never be intentionally clipped during cholecystectomy. Injury to the right hepatic artery is classified as a vasculobiliary injury requiring specialized management. 1
Critical Safety Considerations:
The cystic duct should be transected at its junction with the gallbladder infundibulum to avoid mistaking the common bile duct for the cystic duct. 5
Inadequate identification of the gallbladder-cystic duct junction can result in incomplete cholecystectomy with subsequent bile leaks or recurrent symptoms. 6
The sequence of clipping depends on anatomy: If the cystic artery lies posterior to the cystic duct, clip the duct first; if anterior, clip the artery first. 5