Intraoperative ultrasound significantly improves safety during complex laparoscopic cholecystectomy.

• Intraoperative ultrasound reduced intraoperative iatrogenic rupture from 17.11% to 3.95% (p = 0.017).
• It improved differentiation between cystic duct stones and adhered structures.

Integrating ultrasound with the modified gallbladder reporting and data system enhances decision-making, especially in higher-risk cases.

• The rate of atypical hyperplasia increased significantly in patients with GB-RADS classifications 2b and 2c (p = 0.002).