European Journal of Cardiovascular Medicine

Acute cholecystitis (AC) is an inflammatory condition of the gallbladder most commonly caused by cystic duct obstruction from gallstones, leading to gallbladder distension, ischemia, bacterial colonization, and systemic inflammatory response.1 AC contributes substantially to emergency admissions and healthcare expenditure worldwide, with increasing trends reported in large administrative datasets.2 Contemporary practice has evolved from delayed elective surgery toward early definitive surgery, supported by better perioperative care, improved laparoscopic expertise, and evidence-based guidelines.3

The Tokyo Guidelines 2018 (TG18) standardized AC diagnosis and severity grading (Grades I–III), integrating clinical findings, systemic inflammation markers, and imaging.4 TG18 also proposed management flowcharts, recommending early laparoscopic cholecystectomy (LC) for most Grade I–II patients and selected Grade III patients in experienced centers, with careful patient selection and risk stratification.5 A key TG18 advance is emphasis on preventing bile duct injury through “safe steps” in LC—critical view of safety, bail-out strategies (subtotal cholecystectomy), and early conversion when anatomy is unclear.6 The World Society of Emergency Surgery (WSES) 2020 update similarly endorses LC as the preferred approach for acute calculous cholecystitis when feasible, highlighting early surgery during the index admission and tailored approaches for high-risk patients.3

Despite guideline support, open cholecystectomy (OC) retains a role. OC may be planned upfront in patients with severe inflammation, suspected malignancy, complex previous upper abdominal surgery, or where laparoscopic expertise/resources are limited. In addition, conversion from LC to OC remains an important safety option in difficult gallbladder cases to avoid vasculobiliary injury.7 Predictive models and meta-analyses show conversion risk increases with male sex, older age, delayed presentation, high inflammatory markers, and imaging findings such as thickened gallbladder wall or pericholecystic collection.7,8

Early LC is associated with faster recovery, reduced pain, fewer wound complications, shorter hospital stay, and improved patient satisfaction compared with open surgery.6,9 However, concerns persist regarding operative difficulty, longer operating time in advanced inflammation, and risk of bile duct injury—especially in severe AC or late presentations.6,10 Recent evidence suggests that with modern techniques, appropriate “bail-out” procedures, and experienced surgeons, early LC can be extended safely even beyond the first week in selected patients.10,11

Given ongoing variability in real-world practice, and the need to contextualize guideline recommendations within hospital settings, this study compares clinical outcomes of LC versus OC in patients with acute cholecystitis, focusing on perioperative metrics, morbidity, and recovery outcomes.

A prospective comparative observational study was conducted in the Department of General Surgery at a tertiary care teaching hospital from January 2023 to June 2023. The study followed institutional ethical standards, and informed consent was obtained from all participants. Study population Adult patients presenting with signs and symptoms suggestive of acute cholecystitis were evaluated. Diagnosis was established using clinical findings (right upper quadrant pain/tenderness, fever), laboratory evidence of inflammation (raised WBC/CRP), and imaging (ultrasound showing gallstones with gallbladder wall thickening/pericholecystic fluid), consistent with TG18 diagnostic criteria.4 Severity grading (Grade I/II/III) was assigned using TG18.4 Patients underwent either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). The choice of approach depended on severity grade, anesthesia fitness (ASA class), imaging complexity, and intraoperative judgment. Conversion from LC to OC was recorded and analyzed as part of operative strategy outcomes. Inclusion criteria 1. Age ≥18 years. 2. Diagnosis of acute calculous cholecystitis (TG18 criteria).4 3. Symptom onset ≤10 days (to reflect typical “early surgery” windows used in major guidelines and studies).3,10 4. Candidates for surgery during index admission (including selected high-risk patients after stabilization). Exclusion criteria 1. Acalculous cholecystitis. 2. Concomitant cholangitis requiring urgent ERCP prior to definitive gallbladder surgery (unless stabilized and cleared). 3. Suspected gallbladder malignancy. 4. Pregnancy. 5. Uncorrectable coagulopathy. 6. Severe cardiopulmonary instability prohibiting general anesthesia. 7. Refusal to consent. Outcome measures Primary outcomes: • Overall postoperative complications (Clavien–Dindo grading). • Length of postoperative hospital stay. Secondary outcomes: • Operative time, blood loss, drain use. • Pain scores (VAS at 24 and 48 hours). • Wound complications, bile leak, intra-abdominal collection, bile duct injury. • Readmission within 30 days. Statistical analysis Continuous variables were expressed as mean ± SD and compared using Student’s t-test (or Mann–Whitney U test where appropriate). Categorical variables were compared using Chi-square/Fisher’s exact test. A p-value <0.05 was considered statistically significant.

Table 1. Baseline demographic and clinical characteristics

OC patients had significantly higher surgical risk (ASA III–IV), longer symptom duration, and greater severity (TG18 Grade II–III), indicating that open surgery was more frequently selected for advanced or higher-risk cases

Table 3. Conversion and reasons (LC group only)

Table 2. Operative findings and intraoperative parameters

LC had shorter operative time and markedly lower blood loss. Higher drain usage and dense adhesions in OC likely reflect more severe disease and difficult operative fields. Bail-out subtotal cholecystectomy was used in both groups as a safety strategy.

Conversion rate (10%) aligns with known predictors in acute inflammation. Most conversions were due to unsafe anatomy, supporting guideline emphasis that conversion is a safety decision, not a failure.6–8

Table 4. Postoperative complications (Clavien–Dindo)

Overall morbidity and wound infections were significantly higher after OC. Major complications were numerically higher in OC but did not reach statistical significance—likely influenced by higher baseline severity and risk profile in OC patients.

Table 5. Pain scores and recovery indicators

LC demonstrated superior early recovery—lower pain and faster mobilization and oral intake—consistent with minimally invasive advantages.

Table 6. Hospital stay, readmission, and overall outcome

LC significantly reduced hospital stay. Readmission and mortality were low overall, with no statistically significant difference, supporting that both approaches are acceptable when appropriately selected—though LC offers better efficiency and recovery.

This study demonstrates that laparoscopic cholecystectomy provides superior postoperative recovery and lower overall morbidity compared with open cholecystectomy among patients undergoing surgery for acute cholecystitis. The findings align with major guideline recommendations that LC should be the default approach in acute calculous cholecystitis when feasible, while emphasizing safety-driven decision-making.3–6

The significantly shorter length of stay and reduced pain in LC patients mirrors the minimally invasive advantage consistently described in the literature. TG18’s “safe steps” framework highlights that LC in acute inflammation must prioritize prevention of bile duct injury through careful dissection, early identification of unsafe anatomy, and bail-out strategies such as subtotal cholecystectomy.6 In our series, conversion occurred in 10% of LC cases, most frequently due to unclear Calot’s anatomy. This is consistent with evidence showing conversion is strongly associated with severe inflammation, delayed presentation, male sex, advanced age, and adverse imaging features.7,8 Recognizing conversion as a protective maneuver is essential, and modern outcome frameworks treat conversion as a safety endpoint rather than a complication.6–8

Our results also show higher wound infection rates after OC, which is a well-recognized drawback of larger incisions, longer immobilization, and greater tissue trauma. While major complications were numerically more frequent in OC, the difference was not statistically significant—likely reflecting that OC patients had higher baseline severity (more TG18 Grade II–III) and higher anesthetic risk (ASA III–IV). This selection effect is common in observational comparisons and underscores why guideline-based stratification is important.4,5

Timing of surgery remains debated in late presenters. Recent studies suggest early LC can be extended beyond the first week in selected patients without significant increase in major complications when performed by experienced teams, supporting more flexible “early” windows than previously used.10,11 In high-risk cohorts, evidence increasingly questions routine percutaneous drainage as a definitive strategy: randomized and meta-analytic data show higher major complication/reintervention rates with drainage compared with cholecystectomy in appropriate candidates.12–14 This supports a broader contemporary trend toward definitive surgery whenever feasible, with drainage reserved for the truly unfit or as a bridge to delayed surgery.3,12–14

Overall, the present findings reinforce that LC is the preferred approach for most acute cholecystitis patients, provided that surgeon experience, institutional capacity, and safety principles are applied. OC remains essential for advanced disease and as a conversion option to prevent catastrophic injury when anatomy is unsafe.

Laparoscopic cholecystectomy is safe and offers better postoperative outcomes than open cholecystectomy in most patients with acute cholecystitis, including shorter hospital stay, lower pain scores, and fewer wound complications. Open surgery remains appropriate for severe disease, complex anatomy, or when conversion is required to ensure operative safety. Implementing guideline-based severity assessment (TG18/WSES) and prioritizing “safe steps” with timely conversion or bail-out subtotal cholecystectomy can optimize outcomes.

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