Publication:

Difficult cholecystectomy: a systematic review of predictive factors, surgical approaches and outcomes

Laparoscopic cholecystectomy is the standard surgical treatment for benign gallbladder disease; however, a substantial proportion of procedures are classified as difficult due to anatomical distortion, inflammation, or technical factors, resulting in increased operative complexity and higher complication rates. This literature review aims to synthesize current evidence regarding predictive factors, classification systems, surgical strategies, and clinical outcomes associated with difficult cholecystectomy. A systematic search was conducted in PubMed (Medline), Scopus, Web of Science, SciELO, and Google Scholar for studies published from 2010 and 2025 in English or Spanish addressing difficult cholecystectomy, predictive factors, classification systems, surgical approaches, and outcomes. The literature consistently identifies advanced age, male sex, obesity, comorbidities, previous abdominal surgery, acute cholecystitis, elevated inflammatory markers, and ultrasonographic findings such as gallbladder wall thickening and impacted stones as key predictors of difficult cholecystectomy. Classification systems including the Tokyo Guidelines, Nassar scale, Parkland grading, and G10 scoring system demonstrate high predictive value for operative difficulty, conversion, and complications. Bailout strategies such as subtotal laparoscopic cholecystectomy, fundus-first technique, and timely conversion to open surgery are associated with improved safety in complex cases. Early identification of predictive factors and systematic use of validated classification systems are essential to optimize surgical planning, reduce complications, and improve patient outcomes in difficult cholecystectomy.