396 A Strategic Toolbox for Managing Difficult Laparoscopic Cholecystectomy

Abstract Introduction The incidence of difficult laparoscopic cholecystectomy has increased post-COVID largely due to the pressure of NHS and underutilization of the index admission surgical management of acute cholelithiasis. Method This oral presentation describes strategies, supported by real operative videos, from prospectively collected data from July 2021 till June 2025 to managing difficult cholecystectomy. Result Optical port between 16-18-cm form xiphoid Safe access Liver-reduction-diet for BMI > 35 Avoid the border line between liver and GB for dissection. Adhere to high dissection line away from liver tissue at least 2-5 mm Dissection Inside Gallbladder Wall, sparing the mucosa (Submucosal dissection) Adherence to the back wall of the GB starting behind the neck (True Callot tringle) to start the posterior widow. Expand the posterior window by dropping the Assumed CA from the GB Early Cholangiogram before any uncertain steps Safe development and achievement of the Cortical view of safety Safely Fundus lift technique Zooming inside narrow Orifice technique Trans vesical approach, especially when suspected cholecysto-enteric fistula or advanced Mirizzi Trans-vesical-cholangiogram, or Choledochoscopy Fundus first approach Subtotal cholecystectomy after cholangiogram or choledochoscope confirming no residual stone left. Cholecystostomy Time out, second opinion or abandon the procedure should be considered at any steps of the previously mentions Conversion to open Conclusions This abstract outlined steps represent a toolbox of "out-of-jail" strategies applicable to cholecystectomy. This abstract might support the need for targeted surgical training and advocate for index admission management and development of specialized services to safely manage this challenging patient group.