Background: Laparoscopic surgery widely, known as single incision laparoscopic cholecystectomy (LC), has been proved as the gold standard surgical technique and is now considered the treatment of choice as well as preferred surgical technique in cholecystectomy. The use of laparoscopic technique in cholecystectomy is widely used for cholelithiasis patients. An abdominal ultrasonography (USG) often precedes this surgery and can verify the diagnosis, as well as help in showing possible complications during the perioperative period. Aim: A prospective study was conducted to evaluate the pre-operative with and without (based on clinical findings) USG findings and predictive difficulties in cholelithiasis patients comparing with surgical findings in LC. The post-operative evaluating criteria were as follows: (1) Duration of surgery, (2) Bleeding, (3) Dissection of Calot’s triangle, (4) Dissection of gallbladder wall, (5) Spillage of bile and stone, (6) Difficulty of gall bladder stone. Methods: We studied and evaluated surgical difficulties in 150 patients of cholelithiasis who underwent abdominal USG test for surgical LC. Variables such as identification and amount of gallstones involved were evaluated, both in pre-operative USG and during surgery to evaluate sensitivity, specificity, concordance and positive and negative predictive values. All patients had routine blood tests (including liver function tests), electrocardiography, chest X-ray, and abdominal ultrasound scan performed preoperatively. All patients received general anesthesia, and the standard Reddick and Olsen technique was performed. The harmonic scalpel was used in all cases. Results: On evaluation of surgical difficulties in cholelithiasis patients, we found 135 females and 15 males for surgical LC. Out of which 36 (24.0%) cases to be predicted as difficult, 26 (17.33%) were laparoscopic converted for open surgery, 36 (24.0%) were technically difficult. 54 (36.0%) cases were predicted easy to perform on USG. On evaluation, our findings were found to be significant, and hence, we concluded that pre-operative ultrasound examination if of importance for predicting difficulties in LC, but still required further studies.