“Tenting” or cephalad/anterior traction on Hartmann’s pouch or the cystic duct changes the geometry of Calot’s triangle and the cystic duct–CBD junction. This pulls the cystic duct insertion and the adjacent CBD upward/anterolaterally, producing a mechanical distortion (kinking/tenting) of the extrahepatic ducts and potentially collapsing or narrowing the lumen. • Because the visual field is two-dimensional and orientation can be misleading laparoscopically, the distorted anatomy can be misidentified as the cystic duct or even the cystic artery causing clip placement at or across the common duct. Cognitive / visual misperception underlies many bile ductinjuries.
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