Rethinking access in difficult gallbladders: The small upper midline incision in high-risk patients

Background: Laparoscopic cholecystectomy is the standard treatment for gallstone disease, but may not be feasible in patients with significant comorbidities, hostile abdomens, or contraindications to pneumoperitoneum. Aims and Objectives: This study evaluated outcomes of open cholecystectomy using a small upper midline incision in high-risk patients. Materials and Methods: A retrospective case series of 53 high-risk patients undergoing open cholecystectomy through a small upper midline incision between October 2018 and October 2025 was conducted. Demographic, perioperative, and post-operative outcomes were analyzed descriptively. Results: Of 53 patients, 69.8% were female, and all had at least one comorbidity. Mean operative time was 28.0±11.0 min. Mean post-operative day 1 (POD 1) pain score, Visual Analog Scale was 5.0±1.3. Post-operative nausea and vomiting occurred in 5.7%, and no surgical site infections were observed. Most of the patients (77.4%) were discharged on POD 1, with a mean hospital stay of 2.2±0.5 days. Conclusion: A small upper midline incision with self-retaining retraction appears to be a feasible open approach for selected high-risk patients requiring cholecystectomy, demonstrating acceptable post-operative pain, low early morbidity, and short hospital stay. Prospective comparative studies are needed.