This approach refers to performing laparoscopic cholecystectomy in all patients at the time of initial surgery, regardless of the presence or absence of gallstones [3]. The rationale behind this approach is based on the increased incidence of gallstones after bariatric surgery compared to the normal population and the low sensitivity and specificity of USG in morbid obesity [14]. The main concern is that the diagnosis of microlithiasis is difficult and incidence might be higher than expected [4].

This is supported by the findings of Fobi et al. who found abnormal findings in gall bladder specimens including gall stones, cholesterolosis and cholecystitis in 75 % of surgical specimens despite negative pre-operative USG. He reported additional time of 15 min with no specific morbidity [2]. Similarly Nougou et al. found some pathology in almost 82 % of specimens with additional 19 min for lap cholecystectomy and no specific morbidity related to it [15]. Liem et al. found gallbladder pathology in 80 % specimens [16]. Guadalajara et al. found gallstones in 24 % of the specimens while pre-operative USG was positive for stones in only 16 % [17]. Obeid et al. did a study to assess the safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis and found that it is as safe as laparoscopic adjustable gastric banding (LAGB) alone [8].

This approach involves performing simultaneous laparoscopic cholecystectomy only in patients with gallstones diagnosed pre/intra-operatively, even if asymptomatic [3, 14]. The rationale behind this is an assumed higher incidence of symptomatic disease as compared to patients without gallstones.

Hamad et al. performed simultaneous cholecystectomy in 16.9 % patients during RYGB and compared outcomes in those who did not have concomitant surgery. These had significantly longer operative time, longer hospital stay and higher major morbidity. There was however no specific morbidity directly related to cholecystectomy [18]. In the series of open gastric bypass of Caruana et al., cholecystectomy was performed after the diagnosis of gallstones by intraoperative palpation of the gallbladder with no significant increase in morbidity but with longer operative time [19]. Ahmed et al. in his series of 400 patients found significant increase in operative time of 29 min with no additional morbidity [20].

Villegas et al. performed simultaneous cholecystectomy on 14 % of patients after intraoperative diagnosis of gallstones or sludge with the aid of laparoscopic ultrasound and patients were adviced prophylactic ursodeoxycholic acid at discharge. On follow up there was a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGB and they concluded that selective cholecystectomy with close patient follow-up is a rational approach [21]. Nagem et al. prospectively followed LRYGB patients and found that 28.9 % patients developed gallstones and 15.8 % patients developed symptoms (biliary pain, acute biliary pancreatitis) [4]. They concluded that it is reasonable to perform cholecystectomy during RYGB in the presence of cholelithiasis or if gallstones develop after the procedure. Thus this approach reduces the potential for future gallbladder-related morbidity and the need for further surgery. Hence this can be a preferred option for patients with simultaneous gallstone disease whether symptomatic or asymptomatic.