The Difficult Gallbladder: Practical Considerations for Performing Safe Cholecystectomy

The management of the difficult gallbladder remains one of the most significant challenges in general surgery. As many as 16% of gallbladders can be classified as "difficult," which also makes the difficult gallbladder one of the most common challenges facing the general surgeon in practice. Despite emphasis on a culture of safety surrounding the performance of laparoscopic cholecystectomy, bile duct injury remains a major problem, occurring anywhere from 0.15 to 0.36% of all laparoscopic cholecystectomies. Many of these cases are frequently litigated successfully, and the long-term quality of life in patients who suffer major bile duct injury is reduced. The following review addresses several key aspects related to the management of the difficult gallbladder. These will include a review of the significance of the problem as well as its associated epidemiology and impact on the health care system. Also, the clinical circumstances that serve to make a gallbladder difficult will be discussed. These include aberrant biliary anatomy, the presence of cholecystitis (either acute or chronic), and cirrhosis. Ways to approach these conditions in a safe manner will be reviewed. Finally, the management of biliary injuries in the acute setting will be reviewed, with special attention to the most appropriate management strategy to adopt in the context of available resources and expertise.