The Intraoperative Difficulty Spectrum of Laparoscopic Cholecystectomy: A Stepwise Analysis of Operative Challenges and Safe Cholecystectomy Strategies

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Background and objective Laparoscopic cholecystectomy (LC) has become the preferred surgical approach for the excision of a diseased gallbladder because of its minimally invasive nature, enhanced safety profile, reduced postoperative complications, faster recovery, and shorter hospital stays. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe Cholecystectomy Program focuses on preventing bile duct injury (BDI) by emphasizing the importance of standardized dissection methods, the Critical View of Safety (CVS), intraoperative imaging, and bailout procedures to reduce complications during LC. Difficult gallbladders remain a significant technical challenge and are associated with an increased risk of BDI. This study aimed to evaluate the stepwise intraoperative challenges encountered during LC and assess the role of contemporary safe cholecystectomy principles in the management of difficult, complex, and reoperative biliary surgery. It also aimed to identify the challenges encountered during LC and improve outcomes through the application of current safe cholecystectomy practices. Materials and methods This study was conducted over one year, from April 2024 to March 2025, at the Department of General Surgery, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab, India. Difficult LC was defined as an operative duration of more than 60 minutes, inability to safely achieve the CVS due to severe inflammation, and/or the need for advanced dissection or laparoscopic bailout procedures. Intraoperative challenges were analysed according to six operative steps: creation of capnoperitoneum, adhesiolysis, achievement of the CVS, cystic pedicle control, dissection of the gallbladder from the cystic plate, and specimen retrieval. The use of near-infrared fluorescence cholangiography (NIRF-C), laparoscopic bailout procedures, and outcomes in complex and reoperative biliary cases were also evaluated. Results Of the 442 patients, 156 (35.3%) underwent difficult LC. The most common intraoperative challenge was adhesiolysis (74.4%), followed by difficulty in achieving the CVS (55.1%), specimen retrieval (30.8%), creation of capnoperitoneum (23.1%), and dissection of the gallbladder from the cystic plate (23.1%). Male sex, acute cholecystitis, previous abdominal surgery, abnormal hepatocystic anatomy, intrahepatic gallbladder, and large or multiple gallstones were the principal factors associated with operative difficulty and prolonged operative time (106.39 ± 21.66 minutes). Laparoscopic bailout procedures were successfully employed when indicated. No BDI, major vascular injury, bowel injury, mortality, or conversion to open surgery was observed. Complex biliary pathologies, including gangrenous or perforated gallbladder, cholecystoenteric fistula, and selected completion cholecystectomies, were successfully managed using a laparoscopic approach. Conclusions A structured, stepwise approach to LC, combined with routine demonstration of the CVS, selective use of NIRF-C, and timely adoption of laparoscopic bailout procedures, facilitates the safe management of difficult and complex biliary disease while minimizing major complications and preserving the benefits of minimally invasive surgery. The proposed stepwise intraoperative safety algorithm provides a practical framework to guide decision-making during difficult LC.

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