Many gallbladder cancer patients thought to be node-negative actually show hidden nodal metastasis, impacting surgical outcomes.

• Of 187 patients, 33.1% classified as clinically node-negative had occult nodal disease upon final pathology.
• Key preoperative predictors included elevated CA19-9, systemic immune-inflammation index, and jaundice.
• Risk of occult nodal disease increases significantly with more elevated markers: from 17.1% with 0 markers to 73.6% with 2-3 markers.

Surgeons should incorporate these factors into preoperative evaluations to refine staging and treatment plans.