**6.2 Bail-out procedures**

The concept of CVS cannot be achieved in every case of cholecystectomy; therefore in those situations, the surgeon shall use alternative methods for safe gallbladder removal—the bail-out manoeuver or another method for cystic duct identification. In the setting of acute cholecystitis, the alternative method "fundusfirst" has a lower conversion rate and a lower percentage of iatrogenic injuries to the biliary tree [24]. The technique of subtotal cholecystectomy is used as a safe method with minimal risk of injury to the vascular or biliary structures with low conversion volume due to the resection border being out of the risk zone [10]. However, this method has higher amounts of surgical site infections, re-interventions, and rehospitalisations with a longer length of stay [25]. Conversion to open cholecystectomy is an option in difficult cases as well. However, the conversion to OC does not reduce the risk of biliary duct injury as showed in the results of the Belgian multicentre study [26]. In the study of 1089 patients with acute cholecystitis, 116 patients (11.7%) underwent the conversion to open cholecystectomy with the biliary duct injury of 13.7% (16 patients) [26]. Major BDI was present in 6.0% (7 cases) and three cases of the major BDI occurred after the conversion to OC [26]. These results point out the risk of BDI in high-risk patients undergoing cholecystectomy even in cases when the conversion to open gallbladder removal is performed [26].

#### *Routine and Innovation in Surgical Therapy of Gallstones DOI: http://dx.doi.org/10.5772/intechopen.100570*

Therefore, the subtotal cholecystectomy is the preferred choice in surgeons who has low experience with the open cholecystectomy with the exception of large periprocedural haemorrhage, when the method of choice is open cholecystectomy [26]. In the case of complicated cholecystectomy, the intraoperative cholangiography may be a useful method for the identification of anatomical structures and abnormalities with the risk reduction of BDI, although the disadvantage is the need for access to the biliary tree. Another option may be the use of perioperative ultrasonography, which, however, necessitates the need for proper ultrasonography training and knowledge among surgeons.
