Abstract

Background: Difficult laparoscopic cholecystectomy (LC) with failure to obtain the Critical View of Safety (CVS) is associated with an increased risk of bile duct injury (BDI) and often necessitates bailout strategies.

Objective: To evaluate the role of laparoscopic linear staplers (LLS) as a bailout strategy during difficult LC when CVS cannot be achieved, focusing on prevention of major BDI (primary outcome) and on conversion to open surgery, postoperative complications, and length of hospital stay (LOS) (secondary outcomes).

Methods: A structured literature review was performed across PubMed/MEDLINE, Scopus, Web of Science, Embase, the Cochrane Library, Dimensions, and open-access databases. Studies published between January 2000 and July 2026 in English or Spanish of adult patients undergoing difficult LC in which LLS were used to control the cystic duct and/or complete a subtotal cholecystectomy as a bailout in the setting of failed CVS or hostile Calot’s triangle. Data extracted comprised patient characteristics, indications, operative technique, stapler use, conversion, postoperative complications, and length of stay. Owing to heterogeneity, a descriptive synthesis was undertaken.

Results: The review identified retrospective cohorts, case series, and technical reports including patients with complex biliary pathology. LLS were most commonly employed for dilated, short, or friable cystic ducts and for reconstituting subtotal cholecystectomy. Across series, only one case of BDI was attributable to LLS-assisted bailout. Selective LLS use was associated with low conversion rates, acceptable overall complication rates, and LOS generally comparable to or shorter than that observed after conversion to open surgery, although bile leak, stone migration, and remnant gallbladder syndrome were reported.

Conclusios: In selected patients with difficult LC and failed CVS, LLS appear to be a useful bailout adjunct that may help preserve a minimally invasive approach. However, current evidence is limited to heterogeneous observational studies. LLS use should be restricted to experienced surgeons within a broader strategy of safe bailout, pending prospective multicenter studies with standardized outcome reporting.

Keywords

laparoscopic cholecystectomy; laparoscopic stapler; bailout surgery; critical view of safety; bile duct injury