Essential strategies for the management of challenging laparoscopic cholecystectomy procedures

Abstract

Laparoscopic cholecystectomy (LC) represents the most frequently conducted surgical intervention for managing symptomatic cholelithiasis. However, in the contemporary context of laparoscopic and robotic cholecystectomy procedures, open cholecystectomy remains a relevant surgical approach that minimizes the risk of severe complications. LC is considered to be a straightforward procedure in approximately 60% of cases and presents no significant challenges for most surgeons. However, in 20%-30% of cases, the procedure involves a moderate level of difficulty, and in 10%-15% of cases, the complexity is substantial, thus potentially requiring conversion to an open cholecystectomy approach and the involvement of a highly experienced surgeon who is proficient in both laparoscopic and open techniques. Existing scoring systems have the potential to predict procedural difficulty. Obesity, cirrhosis, elevated American Society of Anesthesiologists scores, prior abdominal surgeries, and the presence of acute cholecystitis or common bile duct stones have been identified as factors contributing to the complexity of cholecystectomy procedures. Radiological findings such as gallbladder wall thickening, pericholecystic fluid accumulation, and impacted gallstones are also correlated with increased surgical difficulty. Elevated body mass index and increased C-reactive protein levels were identified as significant independent predictors of surgical difficulty during LC in patients with acute cholecystitis. For cases in which the operation is anticipated to be challenging, the utilization of intraoperative imaging techniques (including intraoperative cholangiography, intraoperative ultrasound, and near-infrared cholangiography) is advised. When the safe attainment of the critical view of the hepatocystic triangle is not feasible, alternative surgical strategies [such as subtotal cholecystectomy (STC) or an anterograde approach] should be considered. Conversion to open surgery is recommended in instances of significant hemorrhage, cholecystoenteric fistula, Mirizzi syndrome, or suspected malignancy. Furthermore, consultation with or assistance from an additional surgeon is advised under complex operative conditions. The body-first approach and STC represent significant surgical approaches in cases of severe inflammation and fibrosis (including cholecystitis, choledocholithiasis, and biliary pancreatitis) and anatomical variations. Laparoscopic STC encompasses both fenestrating and reconstituting techniques. Moreover, robotic subtotal fenestrating cholecystectomy is the prevailing technique due to the three-dimensional view. Thus, failure to appropriately manage challenging cases may result in severe complications, given the demanding nature of biliary surgery.

Key Words: Gallbladder diseases; Cholelithiasis; Laparoscopic cholecystectomy; Biliary surgery; Complications; Common bile duct injury; Difficult cholecystectomy; Bailout techniques

Core Tip: Patient safety requires increased caution and precision in decision-making when challenges are experienced during laparoscopic cholecystectomy. It is essential to incorporate valuable available diagnostic tools and alternative bailout operative interventions into the management plan for complex cases, along with recognizing when to stop or convert the approach to open cholecystectomy. Failure to accomplish this task may result in catastrophic complications during the procedure. Training and expertise are necessary preconditions for favorable outcomes.

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the most commonly performed surgical procedure for the treatment of symptomatic cholelithiasis[1-4]. Despite advances in laparoscopic and robotic techniques, open cholecystectomy remains a pertinent surgical option, which is primarily due to the importance of ensuring patient safety and achieving optimal surgical outcomes, thereby reducing the risk of serious complications, especially common bile duct (CBD) injury[1,3]. This catastrophic event, which occurs at the beginning of the introduction of LC, demonstrates a rate of approximately 1%-2%, which is nearly three times higher than that of open cholecystectomy (0.3%-0.6%). However, with increased experience and improved instrumentation, this rate has gradually decreased and is currently observed at 0.22%, which is perhaps even lower than that of open cholecystectomy[5].

Approximately 60% of LC cases are considered to be straightforward in nature, thereby posing minimal technical challenges for most surgeons. However, 20%-30% of procedures exhibit moderate difficulty, thus necessitating increased vigilance, whereas the remaining 10%-15% of procedures are highly complex and often necessitate conversion to open cholecystectomy and the involvement of surgeons with extensive expertise in both laparoscopic and open methods. Inadequate management of these complex cases may lead to severe complications, thus reflecting the inherently demanding nature of biliary surgery[2,3,6,7]. Existing scoring systems have demonstrated utility in predicting procedural difficulty[8-12]. In anticipated difficult cases[13,14], the application of intraoperative imaging techniques, such as intraoperative cholangiography (IOC)[1,15], intraoperative ultrasound (IUS)[16], and indocyanine green (ICG) fluorescence imaging with near-infrared light cholangiography[17-20], demonstrates significant value[16,21], as these methods provide critical guidance for implementing various bailout strategies[2,22-24].

Several patient-related factors, including obesity, cirrhosis, elevated American Society of Anesthesiologists physical status scores, a history of prior abdominal surgeries, and the presence of acute cholecystitis or CBD stones, have been identified as contributors to increased surgical complexity[16,25]. Radiological indicators such as gallbladder wall thickening, pericholecystic fluid accumulation, and impacted gallstones are also associated with increased surgical difficulty[21,25-27].

Notably, elevated body mass index and increased C-reactive protein (CRP) levels have emerged as significant independent predictors of surgical complexity in patients undergoing LC for acute cholecystitis. Conversely, preoperative computed tomography (CT) findings alone have been proven to be insufficiently reliable for predicting procedural difficulty, thus underscoring the continued importance of clinical parameters in preoperative assessment[26].

The critical view of safety (CVS) is a fundamental technique for the accurate identification of the cystic duct and artery. Its application is instrumental in minimizing the risk of CBD injuries and other associated complications that may occur during cholecystectomy, particularly in cases where the abovementioned anatomical elements are not readily recognized[28-32].

When the achievement of the CVS within the hepatocystic triangle is not feasible, alternative surgical approaches such as tube cholecystostomy (a currently abandoned approach), subtotal cholecystectomy (STC), or an anterograde dissection technique should be considered. Conversion to open surgery is advised in the presence of severe fibrosis and hard scar formation that interfere with efficient safe dissection, as well as significant hemorrhage, cholecystoenteric fistula, Mirizzi syndrome, or suspected malignancy[33-37]. Additionally, collaboration with or assistance from an experienced colleague is prudent under complex operative conditions[3,16,38].

The body-first approach has been observed to reduce the rate of conversion to laparotomy and increase the likelihood of completing cholecystectomy without vascular or biliary injury[39-42]. STC constitutes a valuable surgical strategy in scenarios characterized by severe inflammation and fibrosis (such as those encountered in cholecystitis, choledocholithiasis, or biliary pancreatitis) or in the presence of anatomical variations that impede the clear visualization of the CVS, which is necessary for the precise identification of the cystic duct and artery[28,43-46].

Laparoscopic STC (LSTC), which includes both fenestrating and reconstituting approaches, offers potential benefits in the treatment of complex gallbladder conditions[44,45], with evidence indicating rather favorable long-term outcomes[28,46].

Due to its three-dimensional visualization capabilities, the use of robotic subtotal fenestrating cholecystectomy provides several advantages over conventional laparoscopic subtotal fenestrating cholecystectomy. These advantages include a lower incidence of biliary leakage, reduced rates of unplanned endoscopic retrograde cholangiopancreatography (ERCP), a decreased need for conversion to open surgery, and an overall reduction in complication rates[47,48].

Furthermore, both robot-assisted and laparoscopic IOC yield comparable outcomes in patients with complicated gallbladder disease or advanced cholecystitis. Although robot-assisted IOC does not increase the risk of adverse events, it is associated with increased health care costs[49]. Novel evolution involves the use of an intraoperative artificial intelligence system[50] or three-dimensional visualization systems[51], which can increase the degree of view in difficult cases. This review examines the factors contributing to complex cholecystectomies, outlines essential technical aspects that are necessary to ensure procedural safety, and evaluates contemporary diagnostic and interventional approaches, thereby emphasizing the prerequisites for achieving favorable outcomes.

PREOPERATIVE ASSESSMENT

Preoperative assessment for difficult LC is crucial for determining the surgical strategy[52-55]. Based on clinical, laboratory and imaging findings, various scoring systems have been developed[13,14,56-58]. The described preoperative risk factors for difficult LC are shown in Table 1.

Table 1 Preoperative risk factors for difficult laparoscopic cholecystectomy.

n	Factor
1	Obesity
2	Cirrhosis
3	Fatty liver infiltration
4	Elevated American Society of Anesthesiologists score
5	Diabetes mellitus
6	Previous upper abdominal surgery
7	In acute cholecystitis, diabetes mellitus, positive Murphy’s sign
8	Previous acute cholecystitis or percutaneous gallbladder drainage
9	Concomitant common bile duct stones
10	Thickened gallbladder wall in imaging
11	Pericholecystic fluid collection in imaging
12	Impacted gallstone in gallbladder neck in imaging
13	Previous episode of acute biliary pancreatitis
14	C- reactive protein levels > 11 mg/dL in elective procedures

Clinical factors and biomarkers

Previous open upper abdominal operations, including those mainly involving the upper gastrointestinal tract and biliary tree, represent the most high-risk factors for surgical difficulty[59,60]. In the case of previous percutaneous transhepatic gallbladder drainage under imaging control for episodes of acute cholecystitis management, a CRP concentration exceeding 154 mg/dL, an elapsed time of less than 35 days, and the presence of duodenal or stomach adhesions were observed to be independent risk factors for difficult cholecystectomies[61,62].

Despite the recommendation of Tokyo Guidelines 2018 for immediate LC in low-risk patients with acute cholecystitis grade I, conservative treatment may be applied, thus increasing the risk of subsequent difficulty with cholecystectomy[63]. In cases of acute cholecystitis grade II (in which early cholecystectomy is safe and effective), a delay in treatment may lead to difficulty in performing cholecystectomy at a later point in time due to fibrosis and dense adhesion formation[64,65]. Additionally, in cases of acute gangrenous cholecystitis (which is difficult to preoperatively diagnose), fever, diabetes mellitus and a platelet count of less than 275000 per mm³ may be helpful indicators[66].

A scheme of biomarkers in acute cholecystitis for predicting surgical difficulty during LC is shown in Figure 1. Useful serum biomarkers for evaluating the severity of inflammation and the grade of surgical difficulty include the white blood cell count, the neutrophil-to-lymphocyte ratio, platelet count, CRP levels, procalcitonin levels, fibrinogen levels, and D-dimer levels[67-69]. A recent study revealed that the procalcitonin level is more valuable than the CRP level for determining disease severity, with a limit exceeding 1.50 ng/mL[67].

Figure 1 Scheme of biomarkers in acute cholecystitis for predicting the surgical difficulty during laparoscopic cholecystectomy. CRP: C-reactive protein; PCT: Procalcitonin.

Previous acute cholecystitis may cause severe chronic inflammation, thus resulting in gallbladder shrinkage, hepatocystic triangle contraction and liver depression. The latter condition constitutes the pucker sign, which may be detected via preoperative imaging or as an intraoperative visual finding and is an indicator of surgical difficulty during delayed cholecystectomy[4].

A recent large evaluation study of the American College of Surgeons National Surgical Quality Improvement Program (including 387501 laparoscopic cholecystectomies performed from 2012 to 2019) revealed an overall incidence of CBD injury of 0.22%. Multivariate analysis revealed that the lethal triad (including obesity, fatty liver infiltration, and acute cholecystitis) significantly increased the risk of bile duct injury (1.49%) compared with that of patients without this risk triangle (0.09%)[5]. Additionally, a preoperative CRP concentration exceeding 11 mg/dL during elective cholecystectomy is a biomarker of surgical difficulty[70].

Imaging

Preoperative ultrasound (US) showing a thickened wall and a shrinking and impacted stone in Hartmann’s pouch (neck) of the gallbladder (particularly the presence of an impacted stone) predicts surgical difficulty during LC[71].

Contrast-enhanced CT plays a crucial role in anticipating challenging LC procedures, especially by facilitating the detection of severe inflammation, anatomical anomalies, dense adhesions, Mirizzi syndrome, and potential malignancies. Therefore, CT is preferable to US in such cases or in cases of suspected concurrent choledocholithiasis when elevated liver function test findings are present[26,27].

In acute cholecystitis, surgical difficulties include delayed presentation from onset of the disorder[72], diabetes mellitus, fever, positive Murphy sign, leukocytosis with neutrophilosis, an increased neutrophil-to-lymphocyte ratio, and especially high fibrinogen levels and a thickened gallbladder wall on US, with an increase in its transverse diameter[73]. On ERCP-magnetic resonance cholangiopancreatography, a defect of the cystic duct represents a predictor of a bailout operation[24].

INTRAOPERATIVE PREDICTORS

ICG fluorescence

ICG is a nonreactive polypeptide that has a profound affinity for high-molecular-weight plasma proteins. It is cleared by hepatocytes and is subsequently excreted into bile, with an estimated half-life of approximately 3-5 minutes. A specialized system is necessary for visualizing fluorescence images. Intraoperative ICG imaging using near-infrared light cholangiography (which is accomplished through intravenous administration or direct injection into the gallbladder) can facilitate challenging cholecystectomies by accurately delineating biliary and vascular structures and identifying potential biliary leakage[74-78].

The capacity for real-time biliary visualization is essential in intricate scenarios such as acute severe inflammation, dense adhesions, and variations in biliary or vascular anatomy. The navigational advantages afforded by fluorescence imaging can enhance surgical procedures, mitigate the need for conversion or the occurrence of significant complications, and increase both the efficiency and safety of complex LC operations[79]. ICG imaging during LC can prove to be particularly advantageous in delineating biliary anatomy to prevent CBD injuries in difficult cases such as Mirizzi syndrome (particularly in the context of acute cholecystitis)[80].

Cholangiography and US

IOC retains its significance and may continue to confer advantages[1,15] in addition to IUS[16], particularly in instances where there is a suspicion of ductal calculi or ambiguous anatomical structures; moreover, it may be integrated with fluorescence methodologies.

CVS

The development of a technique for the safe identification of the cystic duct and cystic artery resulted in the establishment of the CVS. This approach is not intended as an alternative method for performing LC; rather, it serves as a procedural tool designed to prevent injuries to the biliary tract. The CVS involves detachment of the lower one-third of the gallbladder body from the liver bed; meticulous dissection and clearance of the hepatocystic triangle; and the definitive identification of the two structures entering the gallbladder (the cystic duct and the cystic artery)[81]. These steps collectively constitute the necessary and sufficient conditions for the safe ligation and transection of these structures. The surgical procedure proceeds and is concluded only when all three criteria have been satisfactorily fulfilled[82-86].

A novel six-item procedure-specific objective assessment tool for LC (incorporating the CVS) has been developed to facilitate evaluations of surgical trainees. This instrument includes two retraction components (infundibulum and fundus retraction) and four CVS elements (visualization of the hepatocystic triangle, separation of the gallbladder from the liver, identification of the cystic artery, and identification of the cystic duct). This concise tool has demonstrated high reliability, thus emphasizing its safety in surgical practice. It was specifically designed to support the integration of confidential professional abilities within demanding surgical training programs. When combined with video-based assessments, the use of this tool generates novel datasets that exhibit potential for the development of artificial intelligence applications, including computer vision techniques aimed at automating the assessment process[87].

Intrinsic illumination of the biliary anatomy may be achieved by introducing a specialized instrument (the Prometheus device) through Hartmann’s pouch to the junction with the common hepatic duct. This technique aids in intraoperative anatomical delineation, thereby improving the CVS[88].

Mobilization of the infundibulum can improve visualization within Calot’s triangle, thereby facilitating the achievement of the CVS and the identification of Rouviere’s sulcus as an anatomical landmark for orientation. This process is subsequently followed by meticulous dissection and the application of traction to the infundibulum[89]. The RS (located on the inferior surface of the right lobe of the liver and measuring between 2 and 5 cm in length) and the bile duct-for-you (B4U) imaginary line serve as essential landmarks for preventing CBD injury. The B4U line extends from the RS to the base of liver segment IV, which is directed toward the umbilical fissure. To maintain safety during LC, the dissection plane should consistently be positioned superior to this line[90]. A diagram illustrating the CVS, RS, and B4U is presented in Figure 2.

Figure 2 Diagram illustrating the critical view of safety, Rouviere’s sulcus and bile duct-for-you line. RS: Rouviere’s sulcus; B4U: Bile duct-for-you; CBD: Common bile duct; DU: Duodenum; HA: Hepatic artery; PV: Portal vein.

The most common causes of CVS failure include severe inflammation, scarring, dense adhesions and anatomical abnormalities. To address these challenges, recommended strategies include distended gallbladder aspiration to enhance the operative view, as well as the utilization of the abovementioned IOC, IUS, and ICG imaging procedures to clarify ambiguous anatomical structures. Additionally, alternative bailout techniques, such as the fundus-first approach, STC, or conversion to open surgery, may be employed as necessary. The recognition of the continuity between the cystic duct and the infundibulum constitutes a crucial preliminary step (especially in cases of acute cholecystitis or pronounced fibrosis) in avoiding STC[91].

Posterior infundibular dissection, when employed as the initial surgical step during LC, offers several advantages and is typically recommended for experienced surgeons. This approach minimizes the need for medial and cephalad dissection toward the node of Lund, thereby enhancing the safety of the procedure. The safety of the technique is primarily attributed to the initial dissection along the lateral border of the infundibulum. Consequently, the risk of CBD injury can be effectively reduced to almost 0%[92]. A scheme of risky intraoperative findings for difficult LC is shown in Figure 3.

Figure 3 Scheme of intraoperative risky findings for difficult laparoscopic cholecystectomy. GB: Gallbladder; CVS: Critical view of safety.

BAILOUT OPTIONS

In complex cases in which insurmountable surgical difficulties exist and the CVS is impossible to achieve, surgeons must make crucial decisions to abandon the scheduled LC procedure and choose alternative techniques (including top-down cholecystectomy and STC)[93] or convert to an open procedure[3]. Timely bailouts or “time-outs” and deliberate pauses before clipping or dividing structures, along with proper training and expertise, as well as team communication and error prevention in complex cases, ensure the safety of the patient and prevent disastrous complications[16,34,77,94,95]. The conditions that require conversion from laparoscopic to open cholecystectomy are shown in Table 2.

Table 2 Conditions that required conversion from laparoscopic to open cholecystectomy.

n	Condition
1	Severe fibrosis
2	Hard scar
3	Uncontrolled hemorrhage
4	Cholecystoenteric fistula
5	Mirizzi syndrome
6	Surgeon’s expertise
7	Suspected malignancy

Numerous scoring systems exist for predicting difficult cholecystectomy. These systems help assess risk stratification, guiding preoperative referral strategies to more experienced centers or requesting intraoperative assistance from expert biliary surgeons. However, these scoring systems have limitations that affect their reliability, especially when the risk factors are used in combination; therefore, they are usually assessed on a case-by-case basis. The most practical and commonly used scoring systems are presented in Table 3[96], Table 4[97] and Table 5[98]. A simple management algorithm is presented in Table 6.

Table 3 Randhawa and Pujahari[96] difficulty scoring system for laparoscopic cholecystectomy.

Factors	Score1
Age > 50 years	1
Male gender	1
History of acute cholecystitis	4
BMI > 27.5	1
Abdominal scar	1
Palpable gallbladder	1
GB wall thickness > 4 mm	2
Pericholecystic collection	1
Impacted stone	1

¹Grading: Easy 0-5, difficult 6-10, very difficult >10.

BMI: Body mass index; GB: Gallbladder.

Table 4 Sugrue et al[97] difficulty scoring system for laparoscopic cholecystectomy.

Factors	Score1
Adhesions covering gallbladder	1-3
Distended or contracted gallbladder	1
Unable to grasp gallbladder	1
Stone ≥ 1 cm impacted in Hartmann’s pouch	1
BMI > 30	1
Time to identify cystic artery/duct > 90 minutes	1
Severe inflammation, necrosis, perforation	1

¹Grading: Easy 0-1, moderate 2-4, difficult 5-7, extreme 8-10.

BMI: Body mass index.

Table 5 Nassar et al[98] difficulty grading system for laparoscopic cholecystectomy.

Grade	Factors
I	Floppy GB, clear anatomy
II	Mild adhesions
III	Dense adhesions, difficult dissection
IV	Severe inflammation, empyema, contracted gallbladder
V	Mirizzi syndrome, cholecystoenteric fistula

GB: Gallbladder.

Table 6 Simplified management algorithm for laparoscopic cholecystectomy.

Order	Steps
1	Preoperative clinical, biochemical and imaging assessment
2	Initiation of laparoscopic cholecystectomy
3	Intraoperative imaging utilization if needed
4	Achieving CVS can lead to completion of uneventful procedure
5	Impossible CVS necessitates bailout policy (subtotal laparoscopic cholecystectomy as first choice)
6	Unclear anatomy, persistent bleeding, potential CBD injury at any stage, or suspected malignancy necessitate immediate conversion to open cholecystectomy

CVS: Critical view of safety; CBD: Common bile duct injury.

Body- or fundus-first (top-down cholecystectomy)

Under exigent circumstances, the incidence of bile duct injuries may be significantly mitigated through the implementation of either STC or top-down cholecystectomy, which usually includes either a body-first or fundus-first approach, provided that dissection within the hepatocystic triangle of Calot is judiciously circumvented. The most pronounced biliary and vascular injuries tend to occur after the conversion from laparoscopic to open cholecystectomy[99].

STC

STC is being increasingly adopted as a safe surgical approach for the management of challenging gallbladder cases, with an aim of minimizing the risk of injury to the CBD[2,23,100]. The choice between a laparoscopic procedure and an open procedure depends on the surgeon’s expertise[36]. STC provides a viable alternative to total cholecystectomy in complex clinical scenarios; however, the occurrence of bile leakage continues to represent a significant postoperative complication[77,101]. The application of a falciform ligament patch[83] or an omental patch[84] to the sutured gallbladder remnant appears to be an ineffective approach for preventing bile leakage. The type of employed surgical technique and various intraoperative factors have been observed to affect patient outcomes, thus underscoring the importance of standardized surgical protocols and meticulous patient selection[43]. STC is more often performed by experienced biliary surgeons and is accompanied by a lower conversion rate and a shorter duration of operation[42]. However, there is no observable difference with respect to junior and senior general surgeons[102]. Furthermore, STC is more expensive than total cholecystectomy because of postoperative morbidity and the need for readmissions[103,104].

LSTC encompasses two distinct methodologies, including fenestrating and reconstituting approaches. The former method indicates that the gallbladder undergoes partial resection, thus resulting in the remaining portion being in a fenestrated state as opposed to being entirely occluded, which is frequently accompanied by internal suturing of the cystic duct. The latter method indicates that the residual segment is sealed with sutures or staples, thereby resulting in the formation of a novel, diminutive gallbladder[105-108]. Bile leakage is more frequently observed in the fenestrating cohort[109] and may be intraoperatively or postoperatively managed by using endoscopic CBD stents[99], whereas the reconstituting cohort demonstrates a higher incidence of severe recurrent biliary pathology[110,111]; however, the frequency of ERCP is lower[112]. Some skepticism exists concerning the long-term outcomes of STC[34]. A recent systematic review and meta-analysis evaluating these methodologies revealed that the fenestrating approach is correlated with an increased incidence of postoperative bile leakage and an increased need for ERCP interventions[29]. The selection between these two methods is contingent upon intraoperative observations, the surgeon’s expertise, and their familiarity with the respective technique. Moreover, there is no notable disparity in postoperative outcomes or quality of life metrics between the two subtypes of STC; thus, the selection of technique should be predicated on intraoperative circumstances. Closure of the cystic duct during fenestrating STC, along with laparoscopic completion, has been observed to be associated with improved postoperative outcomes[113].

Postoperative recurrent symptoms attributable to retained gallstones within the gallbladder remnant may pose diagnostic challenges but can be effectively addressed through laparoscopic completion cholecystectomy[114,115]. Robotic-assisted STC presents a feasible and potentially superior alternative to conventional laparoscopic approaches[116,117]. A recent systematic review and meta-analysis have indicated that compared with open surgical procedures, robotic-assisted cholecystectomies exhibit a lower rate of conversion and possible advantages compared to LC (in the context of the emergency setting). Nevertheless, the evidence remains limited, and although robotic-assisted cholecystectomy may demonstrate certain benefits in this particular clinical scenario, its status as the preferred surgical methodology has yet to be conclusively established[118].

A recent extensive analysis performed in the United States (involving 12 hospitals and 111 surgeons) revealed a prevalence of the overutilization of STC as a bailout intervention, thus necessitating a demand for its circumspection and restriction[119]. Although the short-term outcomes of LSTC are comparable to those of open procedures and are gaining popularity, its long-term outcomes remain uncertain, thereby necessitating further research[120,121]. Currently, approximately 7%-10% of cholecystectomies performed for acute cholecystitis culminate in subtotal cholecystectomies[122].

A recent multicenter cohort investigation involving patients who underwent 727 bailout procedures for severe cholecystitis across 11 multinational medical centers (encompassing 317 LSTC, 172 open STC, and 238 open cholecystectomy procedures) revealed that LSTC constitutes a viable surgical bailout procedure as an alternative to standard LC, which may pose an excessive risk of bile duct injury; conversely, open cholecystectomy persists as a pertinent surgical option[61]. A scheme of the surgical plan for improved safety in challenging laparoscopic cholecystectomies is shown in Figure 4.

Figure 4 Scheme of the surgical plan for improved safety in challenging laparoscopic cholecystectomies. ICGC: Indocyanine green cholangiography; IOC: Intraoperative cholangiography; IUS: Intraoperative ultrasound; CVS: Critical view of safety; GB: Gallbladder; STC: Subtotal cholecystectomy.

CONCLUSION

LC can be challenging to perform in certain situations, thus necessitating expertise and specialized tools. Preoperative assessment of potential risk factors is crucial for the planning of LC. Intraoperative techniques (including ensuring a CVS and utilizing imaging modalities such as ICG and IOC) can be beneficial. The careful identification of surgical challenges and precise dissection are essential methods for preventing major complications (particularly CBD injury). In cases of difficulty, bailout procedures (such as body- or fundus-first approaches, STC or conversion to open surgery) can ensure the safety of the procedure and are reasonable treatment options. The immediate transition to open surgical intervention is a viable and potentially life-saving strategy, especially in situations involving uncontrollable bleeding or difficulties in visualizing anatomy. This decision should not be viewed as a sign of failure; rather, it should be considered as a prudent choice prioritizing patient safety.