Gallstone disease is one of the most prevalent disorders of the biliary tract and an important source of abdominal morbidity. Its occurrence differs across geographic regions, ethnic groups, dietary patterns, and metabolic profiles. In developed populations, gallstones are identified in approximately 10-15% of adults, although marked variation exists across communities [1,2]. In South Asia, the epidemiological burden is heterogeneous and is influenced by changing nutrition, urbanization, obesity, diabetes, and genetic susceptibility [3,4]. A substantial proportion of gallstones remain asymptomatic; however, symptomatic disease produces recurrent biliary colic, acute or chronic cholecystitis, pancreatitis, choledocholithiasis, cholangitis, and, infrequently, gallbladder malignancy. Repeated inflammatory episodes progressively alter the gallbladder wall and surrounding tissue planes, creating a direct link between clinical history, imaging abnormalities, and the technical demands encountered during definitive surgery.

Age, female sex, obesity, metabolic disorders, rapid weight change, pregnancy-related hormonal exposure, and family history are established contributors to cholesterol stone formation [1-3]. Women are affected more frequently than men, particularly during middle age. Nevertheless, male patients and older individuals can present with more advanced inflammation and technically difficult surgery. Ultrasonography remains the principal initial imaging investigation because it identifies the number and size of stones, gallbladder wall thickening, luminal distension or contraction, pericholecystic fluid, common bile duct dilatation, and impacted stones. These findings contribute not only to diagnosis but also to preoperative anticipation of surgical complexity.

Laparoscopic cholecystectomy is the preferred definitive treatment for symptomatic gallstone disease. Despite its routine use, the procedure can become difficult when dense adhesions obscure the gallbladder, chronic fibrosis contracts the organ, acute inflammation distorts Calot’s triangle, or an impacted Hartmann’s pouch stone limits safe dissection. Operative difficulty is clinically relevant because it increases operative duration, bleeding, bile or stone spillage, drain use, conversion to open surgery, postoperative complications, and hospitalization [5-8]. Predicting these conditions before surgery enables appropriate operating-room preparation, assignment of experienced surgeons, informed patient counselling, and early adoption of bailout techniques when the critical view of safety cannot be achieved [9-11].

Regional observational data that connect clinical presentation and ultrasonographic patterns with direct operative findings remain useful because disease expression and referral practices differ between institutions. The present study was therefore conducted to describe the demographic and clinical profile of patients undergoing cholecystectomy, characterize ultrasonographic patterns of gallstone disease, document intraoperative and histopathological findings, and determine the factors associated with difficult cholecystectomy and adverse postoperative outcomes at Government Medical College, Srikakulam, Andhra Pradesh, India.

Study design and setting: This hospital-based prospective observational study was conducted in the Department of General Surgery, Government Medical College, Srikakulam, Andhra Pradesh, India.

Study period: Patient recruitment and data collection were undertaken from June 2023 to September 2023.

Study population and sample size: Adult patients admitted with symptomatic ultrasonographically confirmed gallstone disease and scheduled for cholecystectomy were screened consecutively. The minimum sample was estimated using n=Z²pq/d², taking an expected proportion of 50%, 95% confidence level, and 10% absolute precision; the calculated value was 96 and was rounded to 100. All 100 eligible patients enrolled during the study period were included.

Eligibility criteria: Patients aged 18 years or older with biliary colic, chronic calculous cholecystitis, or acute calculous cholecystitis who underwent an intended laparoscopic cholecystectomy were eligible. Patients undergoing primary open cholecystectomy, those with acalculous cholecystitis, preoperatively suspected gallbladder malignancy, severe uncontrolled coexisting illness precluding surgery, or incomplete perioperative information were excluded.

Clinical and radiological assessment: A standardized proforma recorded age, sex, body mass index, diabetes, hypertension, previous abdominal surgery, symptoms, prior acute cholecystitis, fever, jaundice, right hypochondrial tenderness, and Murphy’s sign. Preoperative ultrasonography documented solitary or multiple stones, largest stone size, gallbladder wall thickness, gallbladder distension or contraction, sludge, pericholecystic fluid, common bile duct dilatation, and an impacted stone at the neck or Hartmann’s pouch.

Operative assessment: Laparoscopic cholecystectomy was performed using standard institutional technique. Surgeons recorded adhesions, exposure of the gallbladder, condition of Calot’s triangle, distension or fibrosis, impacted stones, empyema, mucocele, gangrenous change, bile or stone spillage, drain placement, operative duration, blood loss, and conversion. Operative difficulty was categorized using an intraoperative assessment adapted from established difficulty-grading principles [8]. Procedures with dense adhesions, marked inflammatory or fibrotic distortion, difficult Calot’s triangle dissection, impacted Hartmann’s pouch stone, major intraoperative event, or conversion were classified as difficult. Safe dissection and bailout decisions followed accepted cholecystectomy safety principles [9-11].

Postoperative assessment: Complications, duration of hospital stay, readmission or reoperation, and mortality were documented. Every gallbladder specimen was submitted for histopathological examination.

Ethical considerations: Necessary permissions were obtained before initiation of this study. Written informed consent was obtained from each participant, and confidentiality was maintained.

Statistical analysis: Data were analyzed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequency and percentage. Difficult and uncomplicated groups were compared using the independent-samples t-test, chi-square test, or Fisher’s exact test, as appropriate. A two-sided p-value <0.05 was considered statistically significant.

A total of 100 patients undergoing cholecystectomy for gallstone disease were included. The mean age was 44.8 ± 12.6 years, and the largest proportion belonged to the 41-50-year age group. Women constituted 64.0% of the study population, producing a female-to-male ratio of approximately 1.8:1. The mean body mass index was 27.1 ± 4.2 kg/m², and 70.0% were overweight or obese. Right upper abdominal pain was reported by 88.0%, followed by biliary colic in 72.0%, dyspeptic symptoms in 52.0%, and nausea or vomiting in 38.0%. A previous episode of acute cholecystitis was documented in 26.0% (Table 1).

Table 1. Demographic and clinical characteristics of the study participants

BMI: Body mass index; SD: Standard deviation. Patients could have more than one presenting symptom or clinical sign.

Ultrasonography demonstrated multiple gallstones in 62.0% and a solitary gallstone in 38.0%. The largest stone measured 1-2 cm in 48.0% of patients. Gallbladder wall thickness greater than 4 mm was observed in 28.0%, a contracted gallbladder in 16.0%, and an impacted stone at the gallbladder neck or Hartmann’s pouch in 14.0%. Common bile duct dilatation and pericholecystic fluid were identified in 8.0% and 10.0%, respectively (Table 2).

Table 2. Ultrasonographic patterns of gallstone disease

Elective cholecystectomy was performed in 84 patients, whereas 16 underwent surgery during an acute admission. Laparoscopic cholecystectomy was completed in 94.0%; six patients required conversion because of dense adhesions, poorly defined Calot’s triangle anatomy, bleeding, or a severely contracted gallbladder. Pericholecystic adhesions were encountered in 58.0%, including dense adhesions in 26.0%. Difficult Calot’s triangle dissection occurred in 24.0%, while empyema and gangrenous changes were observed in 8.0% and 4.0%, respectively. The mean operative duration was 62.4 ± 18.7 minutes, and mean estimated blood loss was 44.6 ± 28.3 mL (Table 3).

Table 3. Operative characteristics and intraoperative findings

Twenty-eight patients were classified as having a difficult cholecystectomy. Male sex, age above 50 years, body mass index ≥25 kg/m², previous acute cholecystitis, gallbladder wall thickness >4 mm, contracted gallbladder, and an impacted neck or Hartmann’s pouch stone were significantly associated with operative difficulty. Multiple stones were more frequent in difficult procedures, but the difference was not statistically significant. Difficult procedures had longer operative duration, greater estimated blood loss, higher conversion and drain-placement rates, more bile spillage and postoperative complications, and longer hospitalization (Table 4).

Table 4. Factors associated with difficult cholecystectomy and postoperative outcomes

        BMI: Body mass index. Values are expressed as frequency (percentage) or mean ± standard deviation.

Postoperative complications were recorded in 10 patients. Port-site infection occurred in five, transient bile leakage in three, subhepatic collection in two, postoperative bleeding in one, and retained common bile duct stone in one; some patients experienced more than one event. No major common bile duct injury, reoperation, or mortality was recorded. Histopathology showed chronic calculous cholecystitis in 68 patients, acute-on-chronic cholecystitis in 18, acute cholecystitis in eight, xanthogranulomatous cholecystitis in four, and cholesterolosis in two. No incidental gallbladder malignancy was identified.

The present study characterized gallstone disease and operative findings among 100 patients undergoing cholecystectomy. Women formed nearly two-thirds of the cohort, the mean age was 44.8 years, and the 41-50-year group was predominant. This pattern is consistent with established epidemiological evidence that female sex, advancing age, and metabolic factors increase gallstone formation [1-4]. The high proportion of overweight and obese patients further supports the metabolic contribution to symptomatic gallstone disease. Right upper abdominal pain and biliary colic were the principal presentations, reflecting intermittent cystic duct obstruction and chronic gallbladder inflammation.

Multiple stones were more common than solitary stones, and nearly one-third of the cohort had gallbladder wall thickening. These ultrasonographic features are clinically important because wall thickening, contraction, pericholecystic inflammation, and impacted stones often indicate fibrosis or active inflammation. In this study, 28.0% of procedures were categorized as difficult and 6.0% required conversion. Bhandari et al. reported difficult laparoscopic cholecystectomy in 15.4% and conversion in 8.9% [5], while Nidoni et al. documented a difficult procedure in approximately one-quarter of patients and conversion in 5.6% [6]. Differences across studies likely reflect case selection, acute admissions, surgeon experience, and the criteria used to define difficulty.

Male sex, age above 50 years, elevated body mass index, and previous acute cholecystitis were associated with difficult surgery. Rosen et al. similarly identified obesity, acute cholecystitis, comorbidity, and thickened gallbladder wall as contributors to conversion [7]. The strongest imaging correlates in the present study were wall thickness greater than 4 mm, a contracted gallbladder, and an impacted neck or Hartmann’s pouch stone. These factors create restricted traction, dense adhesions, and distorted anatomy around Calot’s triangle. Their clinical value agrees with validated operative difficulty frameworks that link higher grades with longer procedures, conversion, complications, and hospital stay [8].

Patients in the difficult group experienced substantially longer operative duration, greater blood loss, more drain placement, increased bile spillage, and prolonged hospitalization. These findings underline the need for early recognition rather than prolonged hazardous dissection. The Tokyo Guidelines recommend structured assessment, achievement of the critical view of safety, and timely use of bailout procedures when inflammation prevents safe anatomical identification [9,10]. Multi-society recommendations also emphasize deliberate dissection, intraoperative imaging when anatomy remains uncertain, and subtotal cholecystectomy or conversion when required to prevent bile duct injury [11].

Chronic calculous cholecystitis was the dominant histopathological diagnosis, and no malignancy was detected. Absence of cancer in a cohort of 100 patients is compatible with the generally low frequency of incidental gallbladder carcinoma. However, Poudel and Shah reported incidental cancer in 1.67% of routine specimens [12], and studies assessing selective versus routine examination continue to demonstrate that grossly unsuspected malignancy can occur [13,14]. Routine histopathological evaluation therefore remains prudent in settings where gallbladder cancer has regional relevance.

Limitations

This single-centre study included a modest sample recruited over six months, limiting precision for uncommon complications and incidental malignancy. Consecutive enrolment reduced selection bias, but surgeon experience and operative decision-making were not stratified. The composite definition of difficult cholecystectomy can differ from other grading systems. Multivariable analysis was not performed; therefore, independent predictors could not be distinguished from correlated inflammatory and radiological factors.

Gallstone disease requiring cholecystectomy predominantly affected middle-aged women, with overweight and obesity frequently present. Multiple gallstones were the commonest ultrasonographic pattern, while gallbladder wall thickening, contraction, and impacted neck or Hartmann’s pouch stones identified patients at greater operative risk. Previous acute cholecystitis, male sex, older age, and elevated body mass index were also associated with difficult surgery. Difficult cholecystectomy resulted in longer operations, greater blood loss, increased conversion, more postoperative complications, and prolonged hospitalization. Careful preoperative clinical and ultrasonographic evaluation, experienced surgical supervision, and timely application of safe bailout strategies can improve operative planning and reduce avoidable biliary injury. Routine specimen histopathology remains an important component of complete surgical care.

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