DIFFICULT CHOLECYSTECTOMY: PREDICTIVE FACTORS, SAFETY STRATEGIES, AND PREVENTION OF BILE DUCT INJURY

Abstract

Difficult cholecystectomy is a dynamic operative condition in which inflammation, fibrosis, anatomic distortion, bleeding, or inadequate exposure prevents safe identification of the biliary pedicle. The main hazard is not conversion itself, but persistence based on presumed anatomy, a mechanism associated with iatrogenic bile duct injury. This article analyzes predictive factors, critical view of safety criteria, imaging methods, bailout strategies, and implementation measures applicable across different resource settings. A narrative, critical, descriptive, and structured literature review was conducted in PubMed/MEDLINE, the Cochrane Library, SciELO, LILACS, and surgical society documents through July 2026. Preoperative scores discriminate groups with greater operative complexity but do not replace intraoperative reassessment. In a prospective series, the critical view was achieved in 84.2% of operations and failed in 55.6% and 92.3% of the highest-grade cases. Cholangiography remains useful when anatomy is uncertain, although routine-versus-selective comparisons are limited by confounding. When anatomy cannot be demonstrated, subtotal cholecystectomy reduces hilar dissection, with a higher risk of bile leak after the fenestrating technique. Prevention therefore requires explicit stopping rules, proficiency in bailout procedures, documentation, and training policies adapted to local resources.