AbstractAcute and obstructed gallbladder disease remains one of the most technically demanding challenges in hepatobiliary surgery. Severe inflammation, cystic duct obstruction, fibrosis, and distortion of biliary anatomy significantly increase operative difficulty and the risk of bile duct injury. Although laparoscopic cholecystectomy is the gold standard, difficult cholecystectomy continues to account for a disproportionate share of surgical morbidity. This comprehensive review discusses the pathophysiology, predictors, preoperative assessment, intraoperative challenges, safety principles, bailout strategies, postoperative outcomes, and evolving concepts in the management of acute and obstructed gallbladder, with emphasis on patient safety and evidence-based surgical judgment.