Safety and Efficacy of Retrograde Versus Conventional Technique in Difficult Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is the standard treatment for calculous cholecystitis due to its minimal invasiveness and favorable postoperative outcomes. However, difficult laparoscopic cholecystectomy remains a significant surgical challenge because of factors like severe inflammation, adhesions, or anatomical anomalies. These factors increase the risk of complications such as bile duct injuries, conversion to open surgery. To enhance safety in such cases, alternative techniques like the retrograde (fundus-first) approach have been proposed. This study was designed to compare the safety and efficacy of the conventional technique and the retrograde technique in difficult LC, with the goal of selecting the most appropriate method for managing these complex cases. Methods: This prospective randomized controlled trial was conducted at the Liver, GIT, and Endo-Lap Surgery Unit, General Surgery Department, Zagazig University Hospital, and involved 32 patients predicted to be cases of difficult cholecystectomy. Preoperative evaluation involved ultrasonographic measurement of gallbladder wall thickness and CBD diameter, along with the Nassar score for predicting surgical difficulty. Results: Mean operative times were similar between groups (53.19±9.32vs. 55.94±13.72 minutes; p=0.66). Intraoperative bleeding was significantly higher in the retrograde group (31.25% vs. 0%; p=0.043). Other intraoperative complications and postoperative recovery parameters showed no significant differences. Conclusion: Retrograde LC is a feasible alternative in difficult cases when conventional dissection is unsafe. However, it may carry a higher risk of intraoperative bleeding, highlighting the importance of careful patient selection and surgical expertise.