Fundus-First Laparoscopic Cholecystectomy in Difficult Gallbladders: A Retrospective Cross-Sectional Study on a Safe Alternative to Avoid Conversion
Conditions: Cholelithiasis
Sponsor: KANAN ISMAYILZADA, MD

Cover Page 
Title of Document: 
Fundus-First Laparoscopic Cholecystectomy in Difficult Gallbladders: A Retrospective 
Cross-Sectional Study on a Safe Alternative to Avoid Conversion 
NCT Number: 
Pending 
Document Type: 
Final Manuscript 
Date: 
 02.08. 2025 
 
 

ABSTRACT 
 
Background: 
Difficult cholecystectomies pose a significant challenge due to severe inflammation and obscured anatomy 
in Calot’s triangle. Fundus-first laparoscopic cholecystectomy (FFLC) has been proposed as a safe 
alternative in such cases. 
 
Methods: 
A total of 124 laparoscopic cholecystectomy (LC) procedures were retrospectively analysed. Surgical 
difficulty was classified using the Nassar scoring system. Cases graded as 3 or 4 were considered ‘difficult 
cholecystectomies’ and were managed using either Calot-first laparoscopic cholecystectomy (CFLC) or 
FFLC. The techniques were compared in terms of operative time, conversion rates, postoperative 
complications and length of hospital stay. 
 
Results: 
Among the 124 cases, 12 were classified as difficult cholecystectomies. CFLC was successfully performed 
in eight cases, with a mean operative time of 38.5 min. FFLC was used in four cases, with a mean operative 
time of 62.5 min. All FFLC procedures were completed laparoscopically without conversion or partial 
cholecystectomy. No bile duct injuries or major complications were observed. Routine drain placement 
enabled early discharge, and complications were minimal. Prophylactic cefazolin was sufficient in most 
cases. 
 
Conclusion: 
FFLC is a safe and effective alternative for managing difficult cholecystectomies, particularly when Calot’s 
triangle dissection is not feasible. While it may prolong operative time, it reduces the need for conversion 
and related complications. Surgeons should be proficient in this approach for optimal outcomes in complex 
gallbladder surgery. 
 
Keywords: fundus-first laparoscopic cholecystectomy; difficult cholecystectomy; Cross-sectional study; 
General surgery; Laparoscopic cholecystectomy, Tertiary care hospital 
 
 
INTRODUCTION 
Laparoscopic cholecystectomy (LC) is one of the most widely performed procedures in modern surgical 
practice. Since the standardisation of Calot’s triangle dissection in 1992 and the introduction of the ‘critical 
view of safety’ (CVS) concept in 1995, conventional laparoscopic cholecystectomy (CFLC) has been 
established as the gold standard [1]. This technique involves meticulous dissection within Calot’s triangle 
to isolate the cystic duct and artery, which are then clipped and transected, followed by gallbladder 
detachment from the liver bed. 
While CFLC is successful in most cases, certain clinical scenarios pose unique challenges. Extensive 
adhesions, severe inflammation, fibrosis or distorted anatomy within Calot’s triangle can compromise 
visibility and hinder safe dissection. These ‘difficult cholecystectomies’ have increased risks, including bile 
duct injury, biliary fistula formation, vascular trauma and heightened perioperative morbidity and mortality. 
In addition, anatomical anomalies and dense adhesions often necessitate conversion to open surgery due to 
the inability to safely delineate structures within Calot’s triangle [2]. 

The fundus-first laparoscopic cholecystectomy (FFLC) technique, introduced by Cooperman in 1990, 
serves as an alternative strategy in such cases [3,4]. Unlike CFLC, FFLC initiates dissection at the 
gallbladder’s fundus and progresses towards Calot’s triangle, allowing the gradual exposure of obscured 
structures while minimising the risks of bile duct and vascular injuries. This method is particularly 
beneficial in acute or chronic cholecystitis, in which severe inflammation obscures Calot’s anatomy. 
Given these considerations, FFLC provides an effective alternative to CFLC in difficult cases, potentially 
reducing conversion rates while maintaining a minimally invasive approach. This study aims to compare 
FFLC with CFLC in managing difficult cholecystectomies and to explore the technical nuances involved in 
FFLC. 
This study has been reported in line with the STROCSS 2025 criteria (35). 
 
METHODS 
This retrospective cross-sectional study analysed 124 LC procedures performed between January 2023 and 
March 2024. Surgical difficulty was classified using the Nassar scoring system, and cases graded as 3 or 4 
were designated as ‘difficult cholecystectomies. FFLC was used exclusively in cases in which CFLC was 
deemed unfeasible due to obscured anatomy or severe inflammation. 
This study compared CFLC and FFLC based on operative time, postoperative complications, conversion 
rates, additional trocar placement, postoperative drain usage and hospital discharge times. 
 
Nassar Scoring System 
The Nassar scoring system, introduced in 1995, categorises the intraoperative difficulty of LC based on 
findings related to the gallbladder, cystic pedicle and extent of adhesions [5]. A revised version in 1996 
added grade 5, which includes complex conditions such as Mirizzi syndrome type 2, cholecystocutaneous 
fistulas and biliary-enteric fistulas. 
 
1. 
Grade 1: Soft gallbladder with no adhesions; thin, easily identifiable cystic pedicle.  
Figure 1.  
2. 
Grade 2: Distended or stone-filled gallbladder; moderately thickened cystic pedicle.  
Figure 2.  
 
3. 
Grade 3: Fibrotic or adherent gallbladder due to acute cholecystitis; complex, short or unclear 
cystic pedicle; dense adhesions. 
  

Figure 3.  
4. 
Grade 4: Gangrenous or empyematous gallbladder; cystic pedicle obscured by inflammation or 
fibrosis; extensive adhesions. 
Figure 4.  
 
FFLC Technique 
All LC procedures adhered to the principles of the CVS. A hook cautery was used as the primary dissection 
tool, and hemolock clips were used to secure the cystic artery (single clip) and cystic duct (two clips) 
before transection. 
In difficult cholecystectomy cases, various techniques—including hydrodissection, gauze-assisted blunt 
dissection and the use of fine-tip dissectors—were employed to facilitate the visualisation of Calot’s 
triangle. When these methods failed to establish a safe operative field, the FFLC approach was initiated. 
Among the 12 difficult cases, eight were managed using CFLC with additional measures, while the FFLC 
technique was necessary in four cases. 
 
FFLC Procedural Steps 
1. 
Initial Setup: The gallbladder fundus was grasped and retracted upward to enhance exposure. In 
cases of severe distension, bile was aspirated via a small fundal incision using a laparoscopic 
aspirator. 
2. 
Dissection: Fundus-to-infundibulum dissection was initiated by incising the peritoneum at the 
gallbladder–liver bed interface using a hook cautery. Gradual traction facilitated dissection despite 
venous bleeding caused by inflammation and fibrosis. Haemostasis and visibility were maintained 
with gauze placement and gentle irrigation (Figure 5). 
3. 
Approach to Calot’s Triangle: Blunt dissection with gauze and hydrodissection techniques was 
utilised to visualise and isolate cystic structures. Increased traction enabled the clear identification 
of the cystic artery and duct, which were then clipped and transected individually (Figure 6). 
4. 
Completion: The surgical field was irrigated and aspirated. Haemostasis in the liver bed was 
achieved using high-voltage spray coagulation with a hook cautery. The gallbladder was retrieved 
using an endobag, and a Jackson–Pratt drain was routinely placed via the right lateral trocar site. 
This systematic approach ensured that all FFLC cases were completed laparoscopically without conversion 
to open surgery or partial cholecystectomy. 
Figure 5.  
Figure 6.  
 

This retrospective study was conducted at a private healthcare institution without an established 
institutional review board. All patient data were anonymised prior to analysis. Informed consent was not 
required due to the retrospective nature of the study and the use of de-identified data, in accordance with 
local ethical standards. 
This retrospective study was not prospectively registered in any research registry. The study design and 
data analysis were conducted in line with the ethical principles of the Declaration of Helsinki. 
 
RESULTS 
Among the 124 LC procedures, 12 cases were identified as difficult cholecystectomies (Nassar grades 3 
and 4). The mean operative time for CFLC was 38.5 min (range: 22–50 min), while FFLC required 
significantly longer, averaging 62.5 min (range: 51–71 min). Despite the increased duration, all FFLC cases 
were successfully completed laparoscopically without conversion to open surgery or partial 
cholecystectomy. Drain placement facilitated smooth recovery, with all patients discharged on 
postoperative day one. No bile duct injuries, vascular trauma, or postoperative infections were observed. 
A single dose of 2 g of intravenous cefazolin was administered perioperatively as an antibiotic prophylaxis 
in all cases. No additional postoperative antibiotic therapy was required, except in two patients with 
gallbladder empyema managed using CFLC. A significant deviation from standard practice was observed 
in the FFLC cases in which a Jackson–Pratt drain was routinely placed. The drains were removed after 24 
h, ensuring adequate monitoring of postoperative haemostasis. 
Notably, all cases were successfully completed laparoscopically, without the need for conversion to open 
surgery or partial cholecystectomy, in either the CFLC or FFLC groups. Furthermore, there were no 
complications/adverse outcomes like bile leaks, intra-abdominal abscesses, or reoperations were observed 
during the follow-up period. 
DISCUSSION 
The findings of this study demonstrate that the fundus-first approach may be particularly beneficial in 
technically demanding cholecystectomies. These findings support the hypothesis that early exposure of 
Calot's triangle via the fundus-first approach in challenging cholecystectomies may facilitate safer 
dissection and minimize conversion risk. 
The terminology distinguishing CFLC and FFLC has been inconsistent in the literature [6]. While CFLC is 
often referred to as ‘retrograde laparoscopic cholecystectomy’, (7) FFLC is sometimes labelled ‘antegrade 
laparoscopic cholecystectomy’ [7–11]. To avoid ambiguity, this study classifies procedures based on the 
site where dissection begins: CFLC at Calot’s triangle and FFLC at the gallbladder fundus. 
Several scoring systems have been developed to assess the difficulty of cholecystectomy, most of which 
rely on preoperative parameters, such as BMI (body mass index), prior abdominal surgeries or radiological 
findings indicative of complicated cholecystitis [12–15]. However, preoperative assessments are inherently 
limited by their reliance on imaging and subjective interpretation. Conversely, intraoperative scoring 
systems are limited in number [16,17] and have not found widespread clinical application, as they have 
been developed based on a restricted number of patients. Moreover, most of these scoring systems are 
designed as a combination of both preoperative and intraoperative findings. Intraoperative scoring systems, 
such as the Nassar scoring system employed in this study, provide a more practical and accurate 

classification based on real-time surgical findings. Nassar’s system has proven to be straightforward, 
reproducible and effective across diverse clinical settings [18]. 
Conversion rates from laparoscopic to open cholecystectomy have been reported in the literature at a range 
of 1.8%–27.7% [19–21]. The most frequent reason for conversion is the inability to safely identify and 
isolate cystic structures due to anatomical anomalies or dense adhesions within Calot’s triangle. While bile 
duct injury during LC occurs at a rate of 0.5%–3%, these injuries are significantly less frequent in open 
procedures (0.1%–0.5%) [22]. However, open conversion is associated with increased postoperative 
morbidity, prolonged hospital stays, delayed recovery and heightened mortality rates [21, 23, 24]. By 
providing an alternative approach in such challenging cases, FFLC has been shown to minimise the need 
for conversion while maintaining patient safety. 
In our series, FFLC was successfully employed in cases in which the anatomy of Calot’s triangle was 
obscured, enabling the completion of all procedures laparoscopically without complications or extended 
hospital stays. The FFLC approach offers a critical advantage over partial or subtotal cholecystectomy [25, 
26], which carries the risks of recurrent cholecystitis and biliary complications [27–29]. Moreover, 
although percutaneous cholecystostomy may serve as a temporary measure in high-risk or elderly patients, 
it is associated with its own set of complications and does not offer the definitive management achieved 
through LC [30–34]. 
The operative durations observed in our study align with previously reported findings. The FFLC cases in 
our series required a mean operative time of 62.5 min, longer than the 38.5 min mean for difficult CLC 
cases. This discrepancy reflects the additional time required to transition to the fundus-first approach after 
failed attempts at dissecting Calot’s triangle. More importantly, despite this increased duration, FFLC 
facilitated safe laparoscopic completion in all cases, avoiding the need for open conversion. 
A key strength of this study is the real-world applicability of the fundus-first technique in a variety of 
difficult cholecystectomy scenarios, reflecting practical surgical decision-making. 
A potential limitation of FFLC is the absence of early vascular control, which can lead to venous bleeding 
from the liver bed. Nevertheless, this challenge can be effectively managed with gauze packing, superficial 
coagulation and meticulous haemostasis techniques. 
Future prospective, multicenter studies with larger sample sizes and standardized grading of gallbladder 
difficulty would be valuable to validate these findings and further refine surgical guidelines. 
 
CONCLUSION 
FFLC is a safe and effective alternative for managing difficult cholecystectomies. By reducing conversion 
rates and preserving the benefits of minimally invasive surgery, FFLC is a valuable addition to 
laparoscopic techniques. Surgeons should be proficient in this method to optimise outcomes in complex 
cases.  
Future studies with larger cohorts and prospective designs are warranted to further validate these findings.  
 
 
 

 
 
 
 
 
 
 
 
Declarations 
Ethical approval: 
This retrospective study was conducted at a private healthcare institution without an established ethics 
committee. All patient data were anonymised prior to analysis, and written informed consent was obtained 
from all patients for the academic use of their clinical information. 
Funding: 
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors. 
Conflict of interest: 
The authors declare that they have no competing interests. 
Author contributions: 
The first author was responsible for study conception and design, data interpretation, manuscript drafting, 
and final approval of the submitted version. The second author contributed through surgical supervision, 
clinical oversight, and critical revision of the manuscript. 
Consent: 
Written informed consent was obtained from all patients for the use of their anonymised data. 
Data sharing statement 
The datasets generated and/or analyzed during the current study are available from the corresponding 
author upon reasonable request. 
Protocol:  
No formal protocol was registered prior to the study due to its retrospective design. 
 
 
 
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FIGURE LEGENDS 
Figure 1. Grade 1 laparoscopic cholecystectomy operating image according to the Nassar scoring system. 
There is no any adhesion and cystic pedicle thin and visible. 
Figure 2. Grade 2 laparoscopic cholecystectomy operating image according to the Nassar scoring system. 
Cystic pedicle fatty but still can easily to dissect pedicle. 
Figure 3. Grade 3 laparoscopic cholecystectomy operating image according to the Nassar scoring system. 
Mobilization is quite difficult due to the increase in wall thickness due to inflammation in the gallbladder. 
Figure 4. Grade 4 laparoscopic cholecystectomy operating image according to the Nassar scoring system. It 
is impossible to identify the cystic pedicle due to extensive adhesions and advanced fibrosis of the 
gallbladder. 
Figure 5. In the FFLC technique, use of gauze in the gallbladder bed and subhepatic area to minimize 
venous leakage from the liver bed and to keep the image clear. 
Figure 6. The cystic duct, which was clipped and cut during FFLC, and the cystic artery, which is still 
dissected.