Implementation of a Bail-out Strategy in Difficult Laparoscopic Cholecystectomy

Background and objectives: Laparoscopic cholecystectomy is the standard treatment for benign gallbladder disease; however, difficult cases may increase the risk of biliary and vascular injury. This study evaluated surgical approach patterns and major injury rates after adoption of a structured bail-out approach.

Methods

This retrospective cohort study included adult patients who underwent cholecystectomy between Sep 2012 and Jul 2025. Patients were divided into a preimplementation period before Jun 2022 and a bail-out period from Jun 2022 to Jul 2025. Demographic characteristics, surgical approach, difficult cholecystectomy cases, and major bile duct or hepatic arterial injuries were analyzed.

Results

A total of 6,701 patients were included: 4,614 in the preimplementation period and 2,087 in the bail-out period. The laparoscopic cholecystectomy rate increased from 75.4% to 85.1% after adoption of the bail-out approach (p < 0.001). During the bail-out period, 51 patients (2.4%) were classified as having difficult cholecystectomy, and conversion to open surgery was required in 12 cases (23.5%). One postoperative intra-abdominal abscess occurred and was managed with drainage. Major injury occurred in 4 patients (0.087%) during the preimplementation period, whereas no major bile duct or hepatic arterial injuries were observed during the bail-out period (p = 0.317).