Intraoperative Variations of Cystic Artery and Duct in Laparoscopic Cholecystectomy: A Systematic Review With Meta‐Analysis

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold-standard treatment for benign gallbladder disease but carries a higher risk of bile duct injury than the open approach, largely due to misidentification of critical hepatobiliary structures. This systematic review and meta-analysis synthesizes intraoperative evidence on the prevalence and surgical relevance of anatomical variations and evaluates their implications for safe LC. METHODS: Following Evidence-based Anatomy and PRISMA 2020 guidelines, four databases were investigated. Random-effects meta-analyses estimated pooled prevalences and small-study effects were assessed. RESULTS: Twenty-seven studies (n = 9618) were included. Conventional cystic artery and duct (CA and CD) anatomy was observed in 86.15% and 89.02% of cases, respectively. Among arterial variants, duplicate CA (7.18%) and caterpillar hump of the right hepatic artery (6.26%) were the most common "third elements" entering the hepatocystic triangle. CA positional deviations included courses posterior (14.95%), anterior (10.75%), and inferior (6.23%) to the CD. Aberrant right hepatic duct entering the hepatocystic triangle was recorded in 1.03%. CONCLUSIONS: Most CA and CD variations relevant to LC occur within the hepatocystic triangle, where they can interfere with identification of the vascular-biliary pedicle and increase the risk of vasculo-biliary injury. Integrating these findings into the cognitive framework of the Critical View of Safety (CVS) highlights the importance of anticipating "third elements" and heterotopic courses when dissecting.