--- title: Not every gallbladder is the same operation publication: Medical Insights Korea section: columns category: Gallbladder canonical_url: https://medicalinsightskorea.com/columns/surgery/not-every-gallbladder-is-the-same-operation author: Jong Je Sung, Specialist in General Surgery author_type: contributing clinician, not editorial staff author_practice: Min Hospital author_credential_issued_by: Ministry of Health and Welfare, Republic of Korea author_profile: https://medicalinsightskorea.com/authors/jong-je-sung editorial_note: Signed opinion by the named clinician. Written by them, edited and translated by Medical Insights Korea. Not a reported article, and not a clinical review of this publication's reporting. published: 2026-09-09T12:41:34+09:00 modified: 2026-09-09T12:41:34+09:00 content_type: opinion license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL. --- # Not every gallbladder is the same operation A surgeon on what repeated inflammation does to the anatomy, why the number of incisions is the wrong thing to compare, and why the decision that matters is the one made mid-operation. ## Answer Removing a gallbladder is a common operation but not a uniform one: a gallbladder holding stones without inflammation and a gallbladder scarred by repeated attacks present differently the moment the abdomen is opened, because inflammation thickens the wall and fuses it to what is next to it until the boundary between the cystic duct, the cystic artery and the bile duct is no longer visible — and acute cholecystitis roughly doubles the odds of bile duct injury; when those structures cannot be identified with confidence the safe course is to change the operation rather than press on with the planned one, converting to a subtotal cholecystectomy or to open surgery, and the number of incisions is not the measure of a good result — across 48 randomised trials single-incision surgery carried about two and a half times the risk of incisional hernia for no advantage in complications. ## Key takeaways - Gallbladder removal is common, but the difficulty is not constant. Repeated inflammation thickens the wall and produces adhesions that hide the normal boundaries. - The anatomy of the cystic duct and cystic artery varies between people, and misreading it is what injures the bile duct. - In a meta-analysis of 31 studies covering 6.5 million cholecystectomies, acute cholecystitis raised the adjusted odds of bile duct injury by 74 percent and male sex by 27 percent. - Gallstones found on a screening scan and causing no symptoms are usually watched rather than operated on; repeated pain or a complication such as cholecystitis, cholangitis or pancreatitis changes that. - When the critical structures cannot be identified, leaving part of the gallbladder behind is the guideline-supported bailout. In a 2026 meta-analysis it carried a bile duct injury rate of 0.3 percent. - That bailout is not free: the same analysis found bile leak in 13.5 percent, retained stones in 6.1 percent, reoperation in 6.3 percent and post-operative ERCP in 16.2 percent, all higher than after a complete removal, though mortality was no different. - Fewer incisions is not the same as a better operation. Across 48 randomised trials, single-incision surgery carried 2.51 times the risk of incisional hernia and took about 15 minutes longer, with no reduction in complications. - Across 96 randomised trials and 11,083 patients, bile duct injury, bile leak and conversion to open surgery did not differ significantly between minimally invasive techniques — the approach is not what makes the operation safe. ## Full article “I have gallstones. Surgery is much the same wherever I have it, isn't it?” It is a question I hear often enough from patients arriving with a screening report in hand, and there is something in it. Removing the gallbladder is one of the operations a general surgeon does most. What is not true is that every one of them is the same operation. A gallbladder that holds stones and has never been inflamed, and a gallbladder that has been inflamed repeatedly until it is stuck fast to what is around it, are two different situations from the moment the abdomen is opened. The same named procedure can differ widely in difficulty and in how it has to be approached. ### What makes one gallbladder harder than another To take a gallbladder out safely, the cystic duct and the cystic artery have to be identified with certainty and dealt with. The difficulty is that the anatomy around them is not the same in everyone. The position of the ducts and vessels and the way they branch vary between people, and where inflammation is severe the tissue swells and adheres until the boundaries that would normally be visible are not. Misjudge a structure there and the bile duct or a neighbouring vessel can be injured. Bile duct injury in particular can lead to a complication serious enough to require further procedures or another operation. That is why an operation this common still turns on taking the time, during it, to confirm what each structure is. > **Which gallbladders the injuries happen in** > A meta-analysis of 31 studies covering 6,513,599 cholecystectomies and 18,259 bile duct injuries found the risk concentrated where the inflammation is: acute cholecystitis raised the adjusted odds by 74 percent, and male sex by 27 percent. Worth noting what the same analysis could not show — neither documentation of the critical view of safety nor routine intraoperative cholangiography was statistically associated with fewer injuries in the pooled data. That is a limit of what large retrospective series can measure, not an argument against identifying the structures. The authors' conclusion is that these patients should be identified as higher risk before the operation, which is the same point being made here. ### Does a gallstone without symptoms need an operation? Finding a gallstone incidentally on a health checkup does not mean it has to come out. Stones causing no pain and no cholecystitis can usually be watched. There are cases in which pre-emptive surgery is considered on the basis of the size of the stone, the state of the gallbladder and other conditions the patient has, so the judgement is an individual one. It is different once a stone is causing repeated pain in the right upper abdomen, or has produced a complication — cholecystitis, cholangitis, pancreatitis. At that point the questions become whether the gallbladder needs to come out and when it is appropriate to do it. ### What repeated inflammation leaves behind Repeated attacks of cholecystitis can make the operation harder. Inflammation that flares and settles, over and over, thickens the wall of the gallbladder and binds it to the tissue around it until the original boundaries are indistinct. Where it has been severe, the duodenum or the colon next to the gallbladder can be adherent firmly enough that separating them safely becomes part of the operation. What matters in that situation is not getting the gallbladder out at any cost, but operating while the structures are being confirmed. Before the cystic duct and cystic artery are divided, the surrounding tissue has to be dissected far enough to make clear what each structure actually is. If they cannot be told apart safely, another route can be taken. Converting to a subtotal cholecystectomy, which leaves part of the gallbladder behind, or to open surgery where that is what the situation calls for — changing the approach to match the patient and what is found during the operation. Recognising a dangerous situation and moving to a safer method is a better judgement than holding to the plan the operation started with. > **What the bailout costs, and what it buys** > A 2026 systematic review and meta-analysis for the Society for Surgery of the Alimentary Tract pooled outcomes after subtotal cholecystectomy for the difficult gallbladder. Bile duct injury occurred in 0.3 percent — the thing it is done to avoid. The price is the rest of the profile: bile leak in 13.5 percent, retained stones in 6.1 percent, complications overall in 24.7 percent, readmission in 17.8 percent, reoperation in 6.3 percent, and endoscopic retrograde cholangiopancreatography afterwards in 16.2 percent, each significantly higher than after taking the whole gallbladder. Mortality, intensive care admission and length of stay were no different. The authors call it a rational bailout when the critical view cannot be achieved, which is exactly the trade being made: a higher chance of a manageable problem in exchange for a lower chance of an unmanageable one. ### Is an operation with fewer holes a better one? Fewer incisions in the abdomen does not necessarily mean a better gallbladder operation. Single-incision laparoscopic surgery, done through one opening, has the advantage of a smaller scar, but which method to use has to be decided from the degree of inflammation and adhesion and the state of the patient. Where the gallbladder is badly inflamed and the surrounding structures are hard to distinguish, securing an adequate view and confirming the ducts and vessels safely comes before the size of the scar. - A meta-analysis of 48 randomised trials, 2,838 patients having single-incision surgery against 2,956 having conventional multiport surgery, found single-incision associated with 2.51 times the risk of incisional hernia (95 percent confidence interval 1.23 to 5.12) and an operation about 15 minutes longer, with complications otherwise equivalent. - A network meta-analysis of 96 randomised trials and 11,083 patients found no significant difference between minimally invasive techniques in bile duct injury, bile leak, intra-abdominal infection or conversion to open surgery. So if an operation is coming, rather than comparing how many holes will be made, it is better to establish first how difficult your own gallbladder is likely to be. If you have been told that cholecystitis has recurred or that the inflammation is severe, the things worth looking at together are whether a high-difficulty gallbladder can be handled, whether the approach can be changed appropriately according to what is found during the operation, and whether the treatment that would be needed afterwards can be carried on if a problem arises. In the end what matters in gallbladder surgery is not making the smallest wound. It is finishing the operation safely, by the method that suits the state of the gallbladder. **What this publication has reported on the same operation** - [Do gallstones without symptoms need surgery?](https://medicalinsightskorea.com/faq/asymptomatic-gallstones-need-surgery) — The evidence on watching rather than operating. ## Sources - Burns R, Connor KL, Guest RV, Johnston CC, Harrison EM, Wigmore SJ, Sherif AE. Risk factors and mitigating measures associated with bile duct injury during cholecystectomy: meta-analysis. BJS Open 2025;9(4):zraf076. doi:10.1093/bjsopen/zraf076. PMID:40751483. https://doi.org/10.1093/bjsopen/zraf076 - Nadeem MA, Awan AR, Wehrle CJ, Tsutsumi A, Darby F, Bhandarkar S, Bentrem D, Allen C, et al. Operative strategies for the acute difficult gallbladder: a Society for Surgery of the Alimentary Tract state-of-the-art systematic review and meta-analysis of subtotal cholecystectomy outcomes. Journal of Gastrointestinal Surgery 2026;30(4):102345. doi:10.1016/j.gassur.2026.102345. PMID:41644007. https://doi.org/10.1016/j.gassur.2026.102345 - Nzenwa IC, Mesri M, Lunevicius R. Risks associated with subtotal cholecystectomy and the factors influencing them: a systematic review and meta-analysis of 85 studies published between 1985 and 2020. Surgery 2021;170(4):1014-1023. doi:10.1016/j.surg.2021.03.036. PMID:33926707. https://doi.org/10.1016/j.surg.2021.03.036 - Lyu Y, Cheng Y, Wang B, Zhao S, Chen L. Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials. Surgical Endoscopy 2020;34(10):4315-4329. doi:10.1007/s00464-019-07198-8. PMID:31620914. https://doi.org/10.1007/s00464-019-07198-8 - Zhao JJ, Syn NL, Chong C, Tan HL, Ng JYX, Yap A, Kabir T, Goh BKP. Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: a systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients. Surgery 2021;170(4):994-1003. doi:10.1016/j.surg.2021.04.004. PMID:34023139. https://doi.org/10.1016/j.surg.2021.04.004 - Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences 2018;25(1):55-72. doi:10.1002/jhbp.516. PMID:29045062. https://doi.org/10.1002/jhbp.516 - Alzoubi M, Omar Saleh A, Omari FA, Shatnawi K, Hyari B, Qashou A, et al. Asymptomatic gallstones: cumulative incidence proportion, incidence rate, and risk factors for symptoms development: systematic review and meta-analysis. PLOS ONE 2026;21(3):e0345462. doi:10.1371/journal.pone.0345462. PMID:41886405. https://doi.org/10.1371/journal.pone.0345462 ## Citation Jong Je Sung (2026). "Not every gallbladder is the same operation". Medical Insights Korea. https://medicalinsightskorea.com/columns/surgery/not-every-gallbladder-is-the-same-operation Retrieved from https://medicalinsightskorea.com/columns/surgery/not-every-gallbladder-is-the-same-operation