pISSN: 2508-5778ㆍeISSN: 2508-5859

Ann Hepatobiliary Pancreat Surg 2023;27:271-276

https://doi.org/10.14701/ahbps.22-127
AHBPS
Annals of Hepato-Biliary-Pancreatic Surgery

Original Article

Laparoscopic cholecystectomy for acute cholecystitis:

Any time is a good time
Hamza Wani1, Sadananda Meher2, Uppalapati Srinivasulu2, Laxmi Narayanan Mohanty2, Madhusudan Modi2, Mohammad Ibrarullah2
1
Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India,
2
Department of Surgical Gastroenterology, Apollo Hospitals, Bhubaneswar, Odisha, India

Backgrounds/Aims: Laparoscopic cholecystectomy within one week of acute cholecystitis is considered safe and advantageous. Sur-
gery beyond first week is reserved for non-resolving attack or complications. To compare clinical outcomes of patients undergoing
laparoscopic cholecystectomy in the first week and between two to six weeks of an attack of acute cholecystitis.
Methods: In an analysis of a prospectively maintained database, all patients who underwent laparoscopic cholecystectomy for acute
cholecystitis were divided into two groups: group A, operated within one week; and group B, operated between two to six weeks of an
attack. Main variables studied were mean operative time, conversion to open cholecystectomy, morbidity profile, and duration of hos-
pital stay.
Results: A total of 116 patients (74 in group A and 42 in group B) were included. Mean interval between onset of symptoms & surgery
was five days (range, 1–7 days) in group A and 12 days (range, 8–20 days) in group B. Operative time and incidence of subtotal chole-
cystectomy were higher in group B (statistically not significant). Mean postoperative stay was 2 days in group A and 3 days in group
B. Laparoscopy was converted to open cholecystectomy in two patients in each group. There was no incidence of biliary injury. One
patient in group B died during the postoperative period due to continued sepsis and multiorgan failure.
Conclusions: In tertiary care setting, with adequate surgical expertise, laparoscopic cholecystectomy can be safely performed in pa-
tients with acute cholecystitis irrespective of the time of presentation.

Key Words: Acute cholecystitis, Laparoscopy, Gangrenous cholecystitis

INTRODUCTION attack. This time frame was called the ‘golden period.’ It was
subsequently realized that the limit of ‘early cholecystectomy’
In the early days, acute cholecystitis (AC) was listed as a could be safely stretched up to one week to 10 days, which
contraindication to laparoscopic cholecystectomy (LC) [1]. formed the basis of the most recent guidelines [3-8]. LC in the
Presence of acute inflammation, difficulty in dissection, and second week is considered formidable. Therefore, LC is recom-
higher chances of complications were initial apprehensions. mended to be deferred beyond six weeks called ‘late cholecys-
With increasing experience, it is now well established that LC tectomy.’ This is done to allow inflammation to subside so that
is safe. In addition, it is more advantageous than open chole- the procedure can be performed electively. In the intervening
cystectomy [2]. Surgery was recommended within 72 hours of period (i.e., from second to sixth week, cholecystectomy is per-
formed for non-resolving cholecystitis or complications such as
Received: December 5, 2022, Revised: January 25, 2023, empyema, gangrene, and perforation). During this period, sur-
Accepted: January 31, 2023, Published online: April 24, 2023 gery is perceived to be technically difficult with attendant high
Corresponding author: Hamza Wani, MS, DrNB conversion & complication rates. Since our center is a tertiary
Department of Surgical Gastroenterology, All India Institute of care center, we often have to operate on such patients referred
Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh 462026, India
Tel: +91-07552982607, E-mail: wanihamza@gmail.com
to us beyond the first week. With considerable experience in
ORCID: https://orcid.org/0000-0002-9417-6220 laparoscopic surgery, we are able to salvage most of these cases
successfully. Encouraged by our results, we decided to subject
Copyright Ⓒ The Korean Association of Hepato-Biliary-Pancreatic Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attri- all our AC patients who were fit for general anesthesia to LC
bution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which
permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original irrespective of the time frame based on the logic that if it could
work is properly cited.

www.ahbps.org
272 Hamza Wani, et al.

be performed successfully under compelling circumstances, it All patients received broad spectrum antibiotics (cefoperazone
could be attempted in a less demanding situation. A prospec- and sulbactam) in the perioperative period. Patients with cho-
tively maintained database of all such patients with AC was an- ledocholithiasis were treated with single sitting LC followed by
alyzed with an aim to evaluate operative issues and immediate endoscopic papillotomy and CBD stone clearance.
outcome of LC performed in the first week and beyond. This Our center is a tertiary care referral center with exclusive
study was approved by Apollo Hospitals’ ethical committee interest in hepatobiliary surgery. The senior most surgeon has
(No. ECR/246/Inst/OR/2013/RR-2016). over 25 years’ experience in laparoscopic surgery. LC was per-
formed by him directly or under his supervision. The operative
PATIENTS AND METHODS time was recorded to grade technical difficulty. Less than one
hour, between one to two hours, and more than two hours were
In a prospectively maintained database, all patients admitted considered as technically easy, moderately difficult, and diffi-
between May 2017 and February 2020 with the diagnosis of cult, respectively.
AC and operated within six weeks of the attack were included
in this study. Patients were divided into two groups: group Techniques of cholecystectomy
A, patients operated within one week of onset of an attack A standard four port approach was adopted. An additional
of AC (early cholecystectomy); and group B, those operated 5 mm port was sometimes used to retract bowel or an over-
between two to six weeks (intermediate cholecystectomy). hanging liver and to improve exposure. The fundus of the
The allocation into respective groups was retrospective and gallbladder (GB) if covered by adhesions was exposed with a
non-randomized. It was based on the timing of presentation gentle sweep using 5 mm suction cannula. The distended GB
only. We followed Tokyo guidelines for the diagnosis of AC was aspirated by using a thick bore needle. The GB fundus was
that was based on clinical presentation, ultrasound imaging, grasped with tooth grasper and firmly retracted up. Adhesions
and hematological parameters [9]. Contrast enhanced comput- on the GB wall were gently swept with a suction cannula. Any
ed tomography (CT) scan was done for doubtful diagnosis or stone impacted in Hartman’s pouch was dislodged if possible
suspected complications such as perforation or gangrene. Mag- and pushed up. Once the Hartman’s pouch was exposed, it was
netic resonance cholangiopancreatography was performed for grasped with a stout tooth grasper. Posterior adhesions were
suspected common bile duct (CBD) stone(s). Charlson Comor- separated gently till it could be freely lifted up. The hepatocys-
bidity Index (CCI) and American Society of Anaesthesiologists tic triangle was dissected to isolate cystic duct (CD) and artery
Physical Status (ASA-PS) classification system were used for after demonstrating critical view of safety (CVS) [12]. If that
risk assessment [10,11]. Patients with CCI ≥ 4 and/or ASA ≥ 3 was not possible, the following techniques were adopted. The
were excluded from this study and managed conservatively or cystic artery was first isolated lateral to the cystic lymph node
by imaging guided percutaneous cholecystostomy. Surgery was close to the GB, clipped, and divided. This could facilitated
performed for these patients electively after their conditions dissection of the CVS. If that too was not possible either, we
improved. In case of non-response or deterioration despite ad- attempted antegrade (fundus-first) technique. The dissection
equate conservative treatment, LC was offered as a last resort. was kept close to the GB as it was mobilized from its bed. The

Total no of patients with gallbladder

diseases seen in study period
(n = 623)

Tokyo guidelines (TG 13)

Diagnosed as Excluded cases ASA PS > 3
acute cholecystitis (n = 3)
(n = 119) Managed conservatively

Group allocation (n = 116)

(laparoscopic cholecystectomy)

Duration of Duration of
symptoms < 7 days symptoms > 7 days
Group A (n = 74) Group B (n = 42)
Follow up
One week post discharge OPD, followed
by telephonic follow up if necessary. Patients
discharged with drain in situ followed up at two
Fig. 1. Flowchart showing the selection of
weeks again for assessment and drain removal.
study subjects. OPD, out patient department.

https://doi.org/10.14701/ahbps.22-127
 Laparoscopic cholecystectomy in acute cholecystitis 273

cystic duct was the last structure to be divided after defining exact test was used to compare results between two groups.
and circumferentially dissecting the infundibulum of the GB.
We used Hem-o-lok clips (Weck Closure Systems) to secure RESULTS
CD if it appeared too short or wide. In certain extremely diffi-
cult situations, we incised the GB neck to deliver the impacted During the duration of this study, there were a total of 623
stone, caught hold of the incised margin, and again tried to dis- patients with GB disease. Of them, 116 patients presenting with
sect structures (CD and artery). If unsuccessful, the Hartman’s AC were included in this study (Fig. 1). They were divided into
pouch was flushed with saline and its interior was inspected for group A (n = 74) and group B (n = 42). The two groups had
any leftover stone fragment(s). The margin was then trimmed, similar demographic characteristics. Clinical presentation, he-
leaving behind just enough healthy tissue for safe approxima- mogram, liver function test, imaging studies, and diagnosis of
tion with interrupted Vicryl suture, close to the presumed CD both groups are summarized in Table 1. Diabetes mellitus (n =
opening (subtotal cholecystectomy, reconstituting type) [13]. 34) and hypertension (n = 33) were the commonest comorbidi-
The excised GB was always delivered through umbilical port ties, followed by hypothyroidism (n = 10), coronary artery dis-
using endo-bag. In situations where the dissection appeared ease (n = 7), asthma (n = 3), chronic renal disease (n = 2), and
hazardous due to dense adhesions and/or obscure anatomy, we others (rheumatic heart disease, thalassemia major, sickle cell
chose to convert to open cholecystectomy. We routinely placed disease, and dilated cardiomyopathy, n = 1 for each). All pa-
suction drain in Hartman’s pouch. When the CD was satisfac- tients who were considered fit for general anesthesia underwent
torily secured with clips, the drain was removed after 24 to 48 LC. Seven patients in our series (4 in group A and 3 in group B)
hours or the patient was discharged with the drain removed had prior infraumbilical abdominal surgery (caesarean section
one week later when he/she returned for suture removal. Fisher in 5 and appendicectomy in 2 patients). There was no patient

Table 1. Clinical presentation, lab reports and final diagnosis

Group A (n = 74) Group B (n = 42) p- value

Demography
Male 35 (47.3) 18 (42.9)
Female 39 (52.7) 24 (57.1)
Mean age (yr) 47.3 (22–68) 48.5 (15–80)
Clinical presentation
Pain 74 (100) 42 (100) NA
Fever 24 (32.4) 8 (19.0) 0.121a)
Jaundice 14 (18.9) 6 (14.2) 0.525a)
Murphy’s sign (+) 57 (77.0) 27 (64.2) 0.140a)
Previous attack of cholecystitis 9 (12.5) 8 (19.0) 0.314a)
Hemogram
Leukocytosis (normal 4,000–11,000/µL) 52 (70.3) 26 (61.9) 0.027*
Liver function test
Serum bilirubin > 2 mg/dL 14 (18.9) 6 (14.3) 0.525 a)
Raised serum transaminase (normal 15–37 U/L) 15 (20.3) 7 (16.7) 0.634 a)
Raised serum transpeptidase (normal 30–65 U/L) 15 (20.3) 7 (16.7) 0.634 a)
Raised serum alkaline phosphatase (normal 50–136 U/L) 27 (36.4) 7 (16.7) 0.024*
Raised serum gama glutamyl transpeptidase (normal 5–55 U/L) 25 (33.7) 8 (19.0) 0.091a)
Final diagnosis
Empyema GB 12 (16.2) 6 (14.2) 0.783a)
GB gangrene/perforation 12 (16.2) 5 (12.0) 0.528a)
Acalculous cholecystitis 1 (1.3) 0 (0) NA
Acute cholecystitis with acute pancreatitis 1 (1.3) 0 (0)
Acute cholecystitis with GB malignancy 1 (1.3) 0 (0) < 0.001*
Acute cholecystitis with choledocholithiasis 1 (1.3) 2 (4.7) 0.297a)

Values are presented as number (%) or mean (range).

GB, gallbladder; NA, not available.
a)
No statistical significance at p > 0.05 level. *Statistical significance at p < 0.05 level.

www.ahbps.org
274 Hamza Wani, et al.

in our series who had or required prior cholecystostomy or any

biliary drainage. Thirteen patients were treated with ‘recon-
stituting type’ subtotal cholecystectomy because of difficulty
in delineating CVS. We did not have to perform subtotal fen-
estrating cholecystectomy in any patient. It was converted to
open in four (3.4%) patients (two in group A and two in group
B). In group A, conversion was because of undissectable Calot’s
triangle anatomy due to superimposed acute pancreatitis in
one and malignant GB neck mass in another. Conversion in
one patient in group B was because of dense pericholecystic
adhesions and intrahepatic abscess. Twelve (16.2%) patients in
group A had gangrenous GB wall/perforation and 5 (12.0%)
patients in group B had similar findings (Fig. 2). Another
patient (male) with multiple co-morbidities had intrahepatic
perforation of GB, leading to liver abscess (Fig. 3). The liver ab-
scess was drained by ultrasound guided catheter. However, he
Fig. 2. Extracted specimen (gangrenous cholecystitis).
continued to be in sepsis. Hence, he was operated upon. Lapa-
roscopy in this patient was abandoned and converted to open
cholecystectomy due to dense pericholecystic inflammatory
adhesions and unclear Calot’s triangle anatomy. This patient ‘intermediate cholecystectomy’) is reserved only for ‘obstinate’
died during the postoperative period due to continued sepsis cases. Although a number of trials are available comparing
and multiorgan failure. Except for this death (0.9%), there were early cholecystectomy and late cholecystectomy, there is a pau-
no major postoperative complications such as CBD injury, bile city of literature on the issue of ‘intermediate cholecystectomy.’
leak, or bleeding. The mean postoperative hospital stay was A multi-center prospective randomized trial from Germany
two days in group A and three days in group B. Histopathology (ACDC Study, NCT00447304) has addressed the issue of im-
of all cases showed features suggestive of AC. mediate cholecystectomy (i.e., within 24 hours of hospitaliza-
tion) vis a vis cholecystectomy after at least two days of antibi-
DISCUSSION otic therapy. Surgery was offered to the latter group within 7
to 45 days of hospitalization [5]. That study was similar to ours
There was an initial reluctance amongst surgeons, exem- with respect to the time frame of LC except that we operated
plified by the fact that in UK and USA, only 20% to 30% of on all patients. We subsequently analyzed the data depending
surgeons were willing to perform LC for AC [14,15]. However, on the day of surgery. Our study was a single center study that
a paradigm shift has seen. Now more than 90% of surgeons are obviated the ‘operator bias’ inherent to a multi-center trial.
willing to perform LC for AC [16]. It is now well established In LC, barring operating surgeon’s experience, major indica-
that ‘early cholecystectomy’ in these patients is as safe as ‘late tors of technical difficulties include operating time, frequency
cholecystectomy’ with added advantages such as reduced cost, of resorting to alternative techniques such as subtotal chole-
shorter hospital stays, and less loss of working days [3,7,17,18]. cystectomy, and rate of conversion from laparoscopy to open
Traditionally, GB in the intervening period (i.e., between two cholecystectomy [19]. The median operation time in our study
to six weeks) is considered ‘untouchable’ and LC (here in called was between one and two hours. There was no significant dif-

A B C D

Fig. 3. (A, B) Contrast enhanced computed tomography scan showing necrotic gall bladder (GB) wall. (C, D) Intrahepatic abscess caused by GB
perforation.

https://doi.org/10.14701/ahbps.22-127
 Laparoscopic cholecystectomy in acute cholecystitis 275

Table 2. Operative details

Group A (n = 74) Group B (n = 42) p- value

Thick walled, edematous, inflamed GB wall 74 (100) 42 (100) NA
Gangrene/perforation of GB 12 (16.2) 5 (11.9) 0.528a)
Impacted stone in Hartman’s pouch 27 (36.4) 13 (31.0) 0.547a)
Both cystic duct & artery identifiable 64 (86.4) 35 (83.3) 0.644a)
Subtotal cholecystectomy 8 (10.8) 5 (11.9) > 0.999a)
Duration of surgery (min) 0.945a)
< 60 31 (41.9) 19 (45.2)
60–90 32 (43.2) 17 (40.5)
90–120 8 (10.8) 5 (11.9)
> 120 3 (4.1) 1 (2.4)
Conversion to open 2 (2.7) 2 (4.7) 0.625a)
Mean postoperative stay (day) 2 (1–6) 3 (1–8)

Values are presented as number (%) or mean (range).

GB, gallbladder; NA, not available.
a)
No statistical significance at p > 0.05 level.

ference in operating time between the two groups, although we cluding image guided percutaneous catheter drainage. The sin-
observed a trend toward a longer operating time in group B. gle death (0.9%) in our series was comparable to the reported
This was similar to the experience reported in the ACDC study mortality incidence of up to 0.8% in various studies [3,5,16,18].
[5]. The incidence of subtotal cholecystectomy was also similar Shortened hospital stay, less hospital cost, and early return to
in both groups. work are proven benefits of early over delayed cholecystectomy
The overall conversion rate of LC has been reported to be for AC [3,18]. The mean postoperative stay in our patients was
1%–15% [15-17,20,21]. The overall conversion rate of LC for AC two days (Table 2). There was no significant difference between
is 6%–34.4% and 45% in a subgroup of patients operated for the two groups, thereby extending advantages of ‘early chole-
non-resolution of symptoms or recurrence of the acute attack cystectomy’ to ‘intermediate cholecystectomy’ group as well.
in the waiting period [3,5,16,17,21-23]. The overall conversion Major limitations of our study were a small case number and
rate in our series was 3.4% without significant difference be- the retrospective nature of analysis. However, this can be used
tween groups A and B. as the basis for planning a prospective multicentric study that
Injury to bile duct is a major concern in LC with an over- can authenticate our findings in the future.
all incidence of 0.1%–0.6% [16,21]. A similar incidence of In a tertiary care setting with adequate surgical expertise, LC
0.07%–0.7% and no difference between early and late interven- can be safely performed in patients of AC irrespective of the
tions have set to rest early apprehensions, making laparoscopy time of presentation. Morbidity, mortality, conversion rates,
equally safe in AC [3,5,6]. We did not have any bile duct injury and postoperative hospital stay of ‘intermediate cholecystecto-
in our experience. There was no significant morbidity either. my’ are similar to ‘early cholecystectomy’ and comparable to
The ACDC study reported a higher incidence of non-biliary those of cholecystectomy performed in elective settings.
complications in the group operated in the second week than
that in the group operated within 24 hours of admission [5]. FUNDING
However, most of these complications were pre-existing, attrib-
utable to the disease itself rather than a delay in surgery. None.
The reasons for this low conversion rate and no major com-
plication like bile duct injury could be due to our longstanding CONFLICT OF INTEREST
tertiary care experience and the operative technique we used
for subtotal cholecystectomy for undissectable Calot’s triangle. No potential conflict of interest relevant to this article was
The latter required not only sound surgical judgment, but also reported.
laparoscopic suturing skills to approximate the residual GB
flap close to the CD opening. ORCID
In our series, one patient in group B died in the postoperative
period due to continued sepsis and multiorgan failure. He was Hamza Wani, https://orcid.org/0000-0002-9417-6220
subjected to LC after exhausting all conservative treatments in- Sadananda Meher, https://orcid.org/0000-0002-8676-0670

www.ahbps.org
276 Hamza Wani, et al.

Uppalapati Srinivasulu, https://orcid.org/0000-0001-6293-7411 classifying prognostic comorbidity in longitudinal studies: develop-

Laxmi Narayanan Mohanty, https://orcid.org/0009-0009-1916-8026 ment and validation. J Chronic Dis 1987;40:373-383.
Madhusudan Modi, https://orcid.org/0000-0002-0734-360X 11. American Society of Anesthesiologists (ASA). ​A SA physical status
Mohammad Ibrarullah, https://orcid.org/0000-0003-1992-701X classification system [Internet]. American Society of Anesthesiolo-
gists 2014 [cited 2023 Jan 1]. Available from: https://www.asahq.org/
AUTHOR CONTRIBUTIONS resources/clinical-information/asa-physical-status-classification-sys-
tem.
Conceptualization: HW, MM, MI. Data curation: HW, SM, 12. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of
US. Methodology: HW, MI. Visualization: HW, US, LNM. biliary injury during laparoscopic cholecystectomy. J Am Coll Surg
Writing - original draft: HW, MI. Writing - review & editing: 1995;180:101-125.
HW, MM, MI. 13. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal cholecystec-
tomy-"fenestrating" vs "reconstituting" subtypes and the prevention
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