Association of Gallbladder Position and Anatomical Variations on Ultrasound with Operative Difficulty during Laparoscopic Cholecystectomy

Abstract

Background: The surgical procedure of choice for symptomatic gallbladder disease is laparoscopic cholecystectomy; however, anatomic variations and inflammatory changes can complicate the procedure. Ultrasonography can provide useful information in the preoperative phase concerning gallbladder position, morphology, wall thickness and abnormalities that predict difficult procedure.

Objective: To determine the association of gallbladder position and anatomical variations detected on preoperative ultrasonography with operative difficulty during laparoscopic cholecystectomy.

Methodology: This prospective observational study was conducted at Khyber Teaching Hospital, Peshawar and Rawal Institute of Health Sciences Islamabad from January 2026 to June 2026 and included 87 patients undergoing elective laparoscopic cholecystectomy. The position of the gallbladder, morphological variations, gallbladder wall thickness, impacted stones of the neck of the gallbladder, pericholecystic fluid and other findings were determined using ultrasonography before operation. The level of difficulty was classified as easy, moderate, difficult or very difficult. Appropriate statistical tests were used to determine the correlations between ultrasonographic findings and operative difficulty, with p < 0.05 deemed significant.

Results: Difficult or very difficult laparoscopic cholecystectomy occurred in 28 (32.2%) patients. Abnormal gallbladder position was significantly associated with difficult surgery compared with normal position (58.3% vs. 22.2%, p = 0.003). Anatomical or morphological variations were also associated with increased difficulty (56.3% vs. 18.2%, p = 0.001). Gallbladder wall thickness >3 mm was associated with difficult surgery in 55.6% of cases (p < 0.001). The highest proportions of difficult procedures were observed in patients with an impacted stone at the gallbladder neck or Hartmann’s pouch (84.6%, p < 0.001) and pericholecystic fluid (80.0%, p = 0.002). Conversion to open surgery was required in 5.7% of patients.

Conclusion: Gallbladder position and anatomical variations identified on preoperative ultrasonography are significantly associated with operative difficulty during laparoscopic cholecystectomy. Particular attention should be given to abnormal gallbladder position, wall thickening, impacted neck stones, and pericholecystic fluid, as these findings may help surgeons anticipate technically challenging procedures and improve operative planning.