The variability in practices related to the utilization of US and cholecystectomy during MBS is significant. Some centers require US for all MBS candidates, while others reserve it for symptomatic patients [1]. There is also a tendency among certain practitioners to perform prophylactic Concomitant Cholecystectomy (CC) on normal gallbladders [10], justified by the aim of preventing postoperative biliary complications despite a lack of supporting evidence [11,12,13]. This inconsistency and lack of standard guidelines result in varying CC rates and practices among surgical centers.

Centers that routinely use US screenings identify many patients with asymptomatic cholelithiasis, with some studies reporting detection rates of up to 15.9% [1]. This proactive approach results in approximately one in six patients benefiting from the detection of gallstones, allowing for prophylactic cholecystectomy [1], a higher incidence of CC alongside MBS [1]. Conversely, selective imaging programs exhibit lower CC rates, as they only operate on symptomatic patients, with some reporting rates as low as 2.4% for symptomatic gallbladders [3, 14].

Previous guidelines have not predominantly advocated for prophylactic cholecystectomy in asymptomatic gallstone cases [15], which explains the hesitance of many surgeons to perform cholecystectomy unless biliary symptoms are present, a position supported by previous recommendations [2, 16]. A multicentric study indicated that routine US is not pivotal in preoperative planning, as most US findings did not affect the surgical approach to the MBS intervention [3]. In such practices, asymptomatic gallstones are often managed conservatively, with either observation or medical prophylaxis.

This divergence in clinical philosophy is underscored by a study conducted in the UAE. In contravention of established guidelines, the surgeons performed CC in over 120 instances of incidental gallstone findings, successfully demonstrating that such procedures can be performed safely without an increase in complication rates when conducted by experienced surgeons [17]. Their rationale for this preventive measure stems from long-term follow-up data indicating that a significant proportion of MBS patients ultimately develop biliary symptoms, though this remains an area of debate [18]. A center’s policy regarding preoperative US directly correlates with the rate of CC. Routine US screening that uncovers silent gallstones can elevate CC rates [1], whereas centers adhering to selective scanning have CC in only a few percent of cases.