Risk factors and outcomes of bailout procedures during laparoscopic cholecystectomy for acute cholecystitis: the BOLAC study

Background: Bailout procedures during laparoscopic cholecystectomy are employed to prevent major complications. However, their incidence, determinants, and clinical impact remain incompletely defined in large multicenter settings. This study aimed to assess the incidence of bailout procedures during laparoscopic cholecystectomy for acute cholecystitis, identify associated risk factors, and evaluate postoperative outcomes. Methods: A retrospective multicenter cohort study was conducted across 22 hospitals in Northern Italy, including consecutive adult patients undergoing laparoscopic cholecystectomy for acute calculous cholecystitis between January 2023 and December 2024. Bailout procedures were defined as any deviation from standard laparoscopic cholecystectomy, including subtotal cholecystectomy or conversion to open surgery. Multivariable logistic regression was used to identify independent predictors. Inter-center variability was assessed using the median odds ratio (MOR). Results: Among 1805 patients, bailout procedures were required in 176 cases (9.8%). The most common strategies were open conversion (4.7%) and laparoscopic subtotal cholecystectomy (3.3%). Failure to achieve the Critical View of Safety was the leading indication (54.2%). Independent predictors of bailout included intramural abscess (OR = 3.25), male sex (OR = 1.74), peritoneal collection (OR = 1.77), and surgical delay > 7 days (OR = 1.85). Significant inter-center variability was observed (MOR = 2.42). Bailout procedures were associated with worse outcomes, including longer hospital stay (11.8 vs. 6.7 days), higher severe complication rates (4.5 vs. 1.6%), increased bile leaks (10.8 vs. 2.3%), and higher readmission rates (6.8 vs. 2.3%). Conclusions: Bailout procedures are required in approximately 10% of LCs for AC and are strongly associated with markers of advanced inflammation and delayed surgery. Their use reflects both disease severity and institutional practice variability and is associated with increased postoperative morbidity. Early intervention and improved risk stratification may optimize surgical planning and outcomes.