This study evaluated the safety and outcomes of fundus-first dissection (FFD) as a salvage technique in 159 laparoscopic cholecystectomies (Nassar Difficulty Grades 4–5) where the critical view of safety (CVS) could not be achieved via antegrade dissection, drawn from a single-surgeon prospective database spanning 1992–2022.
Zero bile duct injuries occurred in 159 FFD cases. Total cholecystectomy was achieved in 96.9%; subtotal cholecystectomy and open conversion were each required in 3.1%. Adverse outcomes were independently driven by ASA ≥ 3 and Grade 5 difficulty — not the FFD technique itself — and conversions fell 35-fold over three decades.
Single-surgeon, single-centre series spanning 30 years limits generalisability; retrospective outcome analysis introduces selection bias; external validation in broader surgical populations has not yet been performed.
When CVS cannot be achieved in a Grade 4–5 laparoscopic cholecystectomy, FFD appears safe in experienced hands — with no bile duct injuries and a 96.9% total cholecystectomy rate. Surgeons should not attribute adverse outcomes to FFD itself; ASA status and anatomical complexity are the key risk drivers.
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