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If the cystic artery was not divided before the cystic duct, it is now carefully isolated by a right-angle clamp similar to those used in isolating the cystic duct (Figure 18). The cystic artery should be isolated as far away from the region of the hepatic duct as possible. A clamp is never applied blindly to this region, lest the hepatic artery lie in an anomalous location and be clamped and divided, resulting in a fatality (Figure 19). Anomalies of the blood supply in this region are so common that this possibility must be considered in every case. The cystic artery is divided between clamps similar to those utilized in the division of the cystic duct (Figure 20). The cystic artery should be tied as soon as it has been divided to avoid possible difficulties while the gallbladder is being removed (Figure 21). If desired, the ligation of the cystic duct can be delayed until after the cystic artery has been ligated. Some prefer to ligate the cystic artery routinely and leave the cystic duct intact until the gallbladder is completely freed from the liver bed. This approach minimizes possible injury to the ductal system as complete exposure is obtained before the cystic duct is divided. If the clamp or tie on the cystic artery slips off, resulting in vigorous bleeding, the hepatic artery may be compressed in the gastrohepatic ligament (Pringle maneuver) by the thumb and index finger of the left hand, temporarily controlling the bleeding (Figure 22). The field can be dried with suction by the assistant, and, as the surgeon releases compression of the hepatic artery, a hemostat may be applied safely and exactly to the bleeding point. The stumps of the cystic artery and cystic duct each are inspected thoroughly and, before the operation proceeds, the common duct is again visualized to make certain that it is not angulated or otherwise disturbed. Blind clamping in a bloody field is all too frequently responsible for injury to the ducts, producing the complication of stricture. Classic anatomic relationships in this area ...

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