IMPORTANCE: Difficult cholecystectomies are associated with a higher risk of severe bilio-vascular injuries. OBSERVATIONS: Obesity, cirrhosis, high American Society of Anesthesiologists score, previous abdominal operations, and presence of acute cholecystitis or common bile duct stones are associated with difficult cholecystectomies. On imaging, thickened gallbladder wall, pericholecystic fluid, and an impacted gallstone are associated with difficult cholecystectomies. In challenging operations, the use of imaging (intraoperative cholangiography, intraoperative ultrasound, near-infrared cholangiography) is recommended. If the critical view of the hepatocystic triangle cannot be safely achieved, bailout strategies, such as tube cholecystostomy, subtotal cholecystectomy, or an anterograde approach, should be considered. Conversion to open surgery should be considered for significant bleeding, cholecystoenteric fistula, Mirizzi syndrome, or malignancy. Seeking advice or assistance from another surgeon is recommended when conditions are challenging. CONCLUSIONS AND RELEVANCE: Knowledge of perioperative and intraoperative adjuncts and alternative surgical options aid surgeons in performing difficult cholecystectomies safely.
