Photo Credit: Shivendu Jauhari

The following is a summary of “Difficult laparoscopic cholecystectomy: a narrative review,” published in the April 2025 issue of BMC Surgery by Abdallah et al. 

Laparoscopic cholecystectomy remains one of the most frequently performed general surgical procedures worldwide. However, the occurrence of difficult laparoscopic cholecystectomy significantly increases operative time, length of hospital stay, complication rates, risk of conversion to open surgery, overall treatment costs, and even mortality. This study aimed to present a comprehensive review of the literature regarding the management of difficult laparoscopic cholecystectomy, focusing on prevention strategies and operative bailout techniques.

A systematic literature review was conducted, encompassing articles published in English through June 2024. Eligible studies included clinical trials, systematic reviews, meta-analyses, and review articles. Studies focusing on pediatric populations, robotic or single-incision laparoscopic cholecystectomy, open cholecystectomy, or cholecystectomy for non-gallstone indications were excluded.

Emergency laparoscopic cholecystectomy for acute cholecystitis achieves the best outcomes when performed within 72 hours of symptom onset, with a maximum operative window extending to 7–10 days. Intraoperative cholangiography serves as a valuable tool to delineate unclear biliary anatomy and facilitates the early detection of bile duct injuries. In situations where the gallbladder becomes “impossible” to dissect safely due to severe inflammation or scarring, laparoscopic cholecystostomy or gallbladder aspiration can provide temporary decompression.

When safe dissection of Calot’s triangle cannot be achieved, the fundus-first (top-down) approach enables the surgeon to complete the procedure with either a total or subtotal cholecystectomy. Subtotal cholecystectomy, in particular, has proven to be an effective bailout strategy for minimizing the risk of bile duct injury. It can often be performed laparoscopically and is considered the most reliable option when traditional dissection planes are obscured.

Difficult laparoscopic cholecystectomy is a frequent and challenging clinical scenario that demands a cautious and skillful surgical approach. An understanding of operative bailout strategies is crucial to patient safety. Among available techniques, laparoscopic subtotal cholecystectomy currently stands as the most effective and safest bailout strategy when conventional dissection proves hazardous.

Source: bmcsurg.biomedcentral.com/articles/10.1186/s12893-025-02847-3