Based on our collected data, we found gallbladder adhesion is quite common (51.6% of patients who underwent laparoscopic cholecystectomy) in our health institutions. We believed most of gallbladder adhesion occurs due to delayed referral of patients. The multilevel referral system in Indonesia significantly prolongs time-to-treat and hence resulting in complications such as gallbladder adhesion. The same problem is also reported in the journal about how Indonesian national health insurance's multilevel referral system prolongs time-to-treat in patients with peritonitis [10]. Adhesion usually follows after 96 h since symptom onset, and therefore early laparoscopic is always recommended to reduce the risk of conversion or difficult laparoscopic cholecystectomy [11].

Cholecystitis with gallbladder adhesion to omentum or bowel can make laparoscopic surgery difficult. Dissection of the adhesion using blunt or sharp technique poses risk of organ perforation or organ injury. The use of cauterization during laparoscopic surgery also poses risk of immediate injury or delayed ischemic injury [12]. The adhesion of gallbladder, which most commonly involves fundus, to the omentum and other organs is considered class I difficulty which has very minimal conversion rate to open surgery. The time for surgery procedure for this difficulty class is also lowest compared to other classes difficulty that involves adhesion in Calot's triangle, adhesion of the gallbladder bed, and other intraabdominal adhesion [6].

Increasing difficulty to access the organ, ongoing inflammation and massive adhesion undoubtedly will increase the difficulty of the laparoscopic surgery and hence the time taken for the surgical procedure becomes longer [7]. One of the most alarming complications that can occur during difficult LC is biliary tract injury. In difficult LC, bile duct injury can occur especially common due to tight adhesion around the neck of the gallbladder [11]. Furthermore, errors during dissection around Calot's triangle, such as misidentification of anatomy and inability to identify injuries, are common technical factors that contribute to biliary injury. Peri-operative bleeding is also linked to an increased risk of significant bile duct injuries during LC [13,14]. Our study shows that only one subject (with <50% adhesion) had CBD injury due to short cystic duct which lies parallel and very closely to the CBD. We believed that this case of CBD is not related to the degree of adhesion. Our statistical analysis also shows that CBD injury has no significant association with degree of adhesion. We believed that this analysis can be further elaborated with bigger sample size to get a more accurate association.

In our study, one patient (in 50% - buried GB group) underwent conversion to open cholecystectomy because of massive adhesion between Hartmann pouch and Calot's triangle. During the laparoscopic surgery, it is difficult to differentiate CBD, cystic duct, and cystic arteries due to the massive adhesion. The laparoscopic surgery made no progress after 30 min and therefore conversion to open surgery is done. Our statistical analysis shows that degree of adhesion has significant correlation with the conversion to open surgery. The analysis shows that degree of GB adhesion has a significance, albeit low degree of correlation, for conversion to open surgery. This aligned with many previous studies which stated that GB adhesion is significant risk factor for conversion surgery [[15], [16], [17]].

Gallbladder adhesion also influence the decision to perform subtotal cholecystectomy instead of total cholecystectomy. Higher degree of adhesion, inflammation, and fibrosis significantly increases the risk of complication, thus resulting in difficult cholecystectomy. Subtotal cholecystectomy is considered in these difficult cases especially when the anomaly involves Calot's triangle [18,19]. Subcostal cholecystectomy has been reported as a reliable cholecystectomy procedure while preventing bile duct injury and avoiding conversion to open cholecystectomy [18]. However, in rare cases, the residue of gallbladder after cholecystectomy can still form gallbladder stones which will cause recurrence of prior symptoms (which is commonly known as post-cholecystectomy syndrome). Redo cholecystectomy can be considered for these cases, Previous studies reported the median time for redo cholecystectomy after the initial procedure varies greatly, ranging from 24 months to 60 months [18]. In the end, resurgery is required to put an end to post-cholecystectomy syndrome, and laparoscopic surgery is proven safe and reliable for complete removal of remnants of the gallbladder and gallbladder stones. In our study, the only one case of resurgery (after total laparoscopic cholecystectomy) was due to subhepatal hematoma which occurred 3 weeks after cholecystectomy. This hematoma was caused by a detached metal clip that was used during the surgery. The dislodged clip may be due to the tissue oedema around the Calot's triangle caused by the massive adhesion. We believed that this is coincidental and a rare occurrence. However, the statistical analysis shows that degree of GB adhesion has a significance, albeit low degree of correlation, for resurgery.