<p>Pediatric laparoscopic cholecystectomy (LC) is increasingly common, but the incidence and clinical implications of retained or spilled gallstones in children remain incompletely characterized. We performed a systematic review of MEDLINE, Embase, Scopus, Web of Science, Google Scholar, and gray literature through 2024, including 12 studies (1057 pediatric LCs). Gallbladder perforation with visible stone spillage occurred in 4.3% (95% confidence interval [CI] 2.9–6.1%) of cases, and clinically significant retained-stone complications—primarily intra-abdominal or port-site abscesses and common bile duct stones—were observed in 1.7% (95% CI 0.9–3.0%). All such complications were successfully managed using endoscopic retrograde cholangiopancreatography, laparoscopic, or percutaneous approaches. Although most spilled stones remain asymptomatic, late presentations up to two years after LC underscore the importance of meticulous retrieval, explicit documentation of spillage, and early imaging for suspicious postoperative symptoms. Existing evidence is constrained by small sample sizes, retrospective designs, and limited follow-up. Nevertheless, it suggests that while gallstone spillage and retention are uncommon in pediatric LC, they can lead to significant morbidity if overlooked. Larger, prospective multicenter registries with standardized definitions, extended follow-up, and robust outcome measures are warranted to clarify true incidence, identify modifiable risk factors, and refine preventive strategies, ultimately improving safety for children undergoing cholecystectomy.</p>