Chronic Cholecystitis: Anatomical Variants, Pediculitis, and a Candidate Preoperative Framework for Difficult Laparoscopic Cholecystectomy

Preoperative risk stratification for laparoscopic cholecystectomy (LC) remains imperfect, particularly in patients with chronic inflammatory remodeling and biliary anatomic variants. Existing tools often focus on acute presentations or intraoperative variables, resulting in uncertainty on how congenital anatomy, recurrent biliary colic, and cystic pediculitis interact. We synthesize a hypothesis-generating conceptual framework and propose an illustrative candidate preoperative rubric for future validation. We performed a structured narrative review of PubMed, Scopus, and Web of Science (January 1990-December 2024; last search: 15 December 2024). Eligible primary studies evaluated clinical history, imaging-defined anatomy, inflammatory biomarkers, and/or operative outcomes (conversion, intraoperative complications, or operative difficulty) in the setting of LC. Acute cholecystitis and chronic/elective cohorts were interpreted separately during the narrative synthesis. Two reviewers screened titles/abstracts and assessed full texts using predefined inclusion/exclusion criteria; due to heterogeneity, no meta-analysis and no formal risk-of-bias tool were applied. The literature supports a plausible vicious cycle in which biliary anatomic variants may impair drainage and promote stasis, recurrent biliary colic, and chronic inflammation, ultimately leading to fibrosis/pediculitis and a "frozen" Calot's triangle. We translate these signals into an illustrative candidate rubric (0-16 points) spanning three domains: clinical history (0-6), imaging (0-6), and inflammatory biomarkers (0-4). Weights and cut-offs (low: 0-4; moderate: 5-9; high: 10-16) were chosen a priori for conceptual clarity and are not data-derived. This review provides a conceptual map and a candidate variable set to support hypothesis generation, standardized data collection, and staged validation. The rubric is not validated and must not be used for clinical decision-making. Planned next steps include feasibility-oriented derivation, followed by prospective multicenter external validation and impact assessment.