Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention. As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes. In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure. 10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic cholecystectomy is a safe and viable option for treating acute calculous cholecystitis

1. SURGERY | ORIGINAL ARTICLE
LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE
CALCULOUS CHOLECYSTITIS (STUDY OF 75 CASES)
Ketan Vagholkar∗,1,a and Shashwat Singh∗∗,a
∗ Professor , ∗∗ Senior Resident , a Department of Surgery, D.Y.Patil University School of Medicine, Navi Mumbai 400706. MS. India
ABSTRACT Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of
laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention.
As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to
evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and
safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients
who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied
prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right
hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes.
In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure.
10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic
cholecystectomy is a safe and viable option for treating acute calculous cholecystitis.
KEYWORDS Acute, calculous, cholecystitis, laparoscopic, cholecystectomy
Introduction
Acute Calculous Cholecystitis is one of the most common biliary
emergencies managed by a general surgeon. The traditional
approach comprising conservative treatment in the acute phase
followed by elective cholecystectomy after 6 weeks is still the
standard approach to treatment. However the advent of la-
paroscopic cholecystectomy has completely revolutionized the
approach to emergency management of gallstone disease. [1]
Emergency laparoscopic cholecystectomy is now a safe and fea-
sible option. As experience with the laparoscopic technique
increased over a period of time, the fear and apprehension re-
lated to emergency laparoscopic cholecystectomy has gradually
declined. The present study aims at evaluating the surgical
efficacy of laparoscopic cholecystectomy in acute cholecystitis.
Copyright © 2022 by the Bulgarian Association of Young Surgeons
DOI: 10.5455/IJMRCR.172-1645540589
First Received: February 22, 2022
Accepted: March 9, 2022
Associate Editor: Ivan Inkov (BG);
1
Corresponding author: Dr. Ketan Vagholkar, Annapurna Niwas, 229 Ghantali Road.
Thane 400602. MS. India. E mail: kvagholkar@yahoo.com, Mobile: + 91 9821341290
Aims and Objectives
The aim of this study is to evaluate the efficacy of laparoscopic
cholecystectomy in acute calculous cholecystitis taking into con-
sideration various aspects associated with the procedure.
1. To evaluate the duration of emergency laparoscopic surgery
for acute calculous cholecystitis.
2. To assess the technical difficulties and intraoperative com-
plications of laparoscopic cholecystectomy in acute cases.
3. To study the conversion rate to an open procedure in acute
calculous cholecystitis.
4. To assess various post-operative complications of emer-
gency laparoscopic cholecystectomy with respect to biliary
tract, vascular and adjacent organ injuries.
5. To evaluate the duration of hospital-stay in patients who
have undergone emergency laparoscopic cholecystectomy.
Materials and Methods
The study was conducted in a single surgical unit of a tertiary
care hospital (DY Patil hospital and research centre, Navi Mum-
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2022) 6(7):61-65

2. Table 1 Distribution of patients with duration of abdominal pain.
Duration of Pain No. of patients
Up to 24 hours 44 (58.6%)
24-48 hours 31 (41.4%)
Total 75 (100)
Table 2 Conversion from laparoscopic cholecystectomy to open cholecystectomy.
Converted to open cholecystectomy 5 (6.67)
Laparoscopic cholecystectomy successfully completed 70 (93.33)
bai, India) in the period from January 2018 to December 2019.
Ethical clearance was obtained from the institutional ethics com-
mittee prior to commencing the study.
Consecutive .patients presenting as acute calculous cholecys-
titis in the period from January 2018 to December 2019 confirmed
by clinical, laboratory, and radiological investigations were in-
cluded in the study.
As this is a hypothesis generating study, a formal sample size
was not calculated.
Inclusion Criteria
Clinical criteria
1. Acute right upper abdominal tenderness with or with-
out fever
2. Positive Murphy’s sign
Laboratory criteria
1. Leukocytosis ( Total WBC count greater than 15000)
2. Normal liver function tests.
Radiological criteria (Ultrasound)
1. Presence of gallstones with a thickened and edematous
gallbladder.
2. Pericholecystic fluid collection.
The most sensitive ultrasound finding in acute cholecystitis
was the presence of cholelithiasis in combination with thickened
gall bladder wall with pericholecystic collection as a secondary
finding.
Exclusion criteria
1. Choledocholithiasis confirmed by radiological investiga-
tions
2. Patients with suspected malignancy
3. Obstructive jaundice presenting with elevated direct biliru-
bin level
4. Cholangitis presenting with Charcot’s triad.
5. Pregnant female patients confirmed by pregnancy test
6. Medically unfit patients due to severe co morbidities.
7. Patients refusing to consent
On admission to hospital the following parameters were as-
sessed
a. Demographic details including age (years) and gender.
b. Clinical presentation - pain in the right upper abdomen
associated with fever and vomiting.
c. Lab investigations - complete blood count, liver and renal
function tests.
d. Radiological investigations which included abdominal ul-
trasound.
Ultrasound was the preferred imaging modality for diagno-
sis of acute cholecystitis. Positive findings included presence of
stones, thickening of gallbladder wall, and pericholecystic col-
lection. MRCP evaluation was done in doubtful cases. The tech-
nique adopted for laparoscopic cholecystectomy was typically
through 4 ports which included sub-umbilical port, epigastric
port, and 2 lateral ports.
Results
1. Age and gender: The mean age of patients was 49.48±16.4
years with the range from 26 to 79 years. 52 patients were
females which accounted for 69% cases while 23 patients
were male which accounted for 31% cases.
2. Pain in abdomen: Pain in abdomen was observed in all
patients. 44 (58.6%) cases presented with acute pain in
abdomen with onset within 24 hours of duration whereas
31 patients presented with pain between 24 to 48 hours.
(Table 1)
3. Site of pain: Majority of patients 58 (77.3%) presented with
pain in right hypochondrium, while 17 (22.7%) patients
presented with pain beyond the right hypochondrium
4. Other symptoms: Acute calculous cholecystitis presented
with symptoms other than pain. A total of 17 (22.7%) pa-
tients had nausea whereas 8 (10.67%) patients had vomiting.
A total of eight patients (10.67%) had both.
5. Comorbidity: In the present study 22 (29.33%) patients had
hypertension, 26 (34.67%) patients had diabetes mellitus,
and six patients (8%) had both.
6. Duration of surgery: Out of 75 patients, the operating time
in 61 patients (81.33%) was less than 60 minutes, and in 14
patients (18.67%) the operating time exceeded 60 minutes.
Mean duration of surgery was 46.68±14.9 minutes.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2022) 6(7):61-65

3. 7. Conversion from laparoscopic cholecystectomy to open
surgery: In the present study, five patients (6.67%) were
converted to an open procedure whereas 70 patients (93.3%)
successfully underwent laparoscopic cholecystectomy with-
out the need to convert. (Table 2)
8. Reasons for conversion: In the present study, iatrogenic
injury during dissection led to conversion in 2 (2.67%) pa-
tients. Excessive bleeding from the gallbladder bed which
could not be controlled by topical haemostatic agents was
seen in one patient (1.33%), and the inability to identify the
junction of cystic duct and the common bile duct due to
adhesions lead to conversion in 2 patients (2.67%) (Table 3)
9. Postoperative complications: In the present study, bile leak
developed in 3 (4%) patients, postoperative fever in four
patients (5.33%), post-operative jaundice was seen in two
patients (2.66%), and peritonitis in one patient (1.33%). (Ta-
ble 4)
10. Hospital-stay: Mean duration of hospital stay of patients
in the present study was 4.34±1.8 days. It ranged between
3 to 10 days. Maximum number of patients i.e., 63 (84%)
patients stayed for less than 5 days in hospital whereas 12
patients (10%) stayed beyond 5 days.
Discussion
Gallstone disease is one of the major causes of abdominal
morbidity. Clinical presentation varies from asymptomatic to
grossly symptomatic cases. Cholecystectomy is the mainstay
of treatment for symptomatic gallstones. The advent of laparo-
scopic cholecystectomy is gradually revolutionizing the treat-
ment of gallstone disease. Early laparoscopic cholecystectomy
performed within 72 hours of symptomatic presentation poses
less technical difficulties and therefore reduced conversion rates
and minimum post-operative complications. [1, 2] This also
obviates another hospital admission.
Calculous cholecystitis is a disease that increases in incidence
as age advances. It is also observed that advanced age is associ-
ated with more complicated diseases. Therefore there is a higher
incidence of conversion to an open procedure in aged patients.
The mean age of patients in the present study was 49.48±16.4
years. Four out of five patients with a mean age of 64.6 years
who underwent laparoscopic surgery needed conversion to an
open procedure. Gallstones also have a predilection for the fe-
male sex. In the present study, 4 female patients were converted
to open procedure while only one male patient required con-
version. Various studies have proved that the male sex is a risk
factor for conversion. [1, 2, 3]
The site of pain and onset in acute calculous cholecystitis is
primarily divided into two specific locations, i.e., the epigas-
trium and right hypochondrium. In the present study, 77.3 %
of patients presented with pain in the right hypochondrium,
whereas only 22.7% of patients presented with epigastric pain.
Furthermore, 44 of the 75 patients had pain with onset less than
24 hours after admission. Thirty-one patients had pain lasting
for more than 24 hours before admission. Patients were taken
for surgery within 48 hours of admission in all cases. Other
associated symptoms were nausea in 22.6 % and vomiting in
10.6% of patients.
Comorbidities add to the risk of conversion. [4, 5] Diabetes
is usually associated with more complicated adhesions neces-
sitating conversion to open procedure. [5, 6, 7] The best time
for laparoscopic cholecystectomy is within the first 48 hours of
symptoms as there is significant tissue oedema which helps in
better dissection.
Ultrasound findings suggestive of acute cholecystitis include
the presence of stone in gallbladder, thickened gallbladder wall,
pericholecystic collection, phlegmon around the gallbladder,
and status of liver and common bile duct (CBD) if it is identi-
fiable. [8, 9, 10] If facilities for MRCP are available, then it is
advisable to do this investigation prior to laparoscopic chole-
cystectomy. This ensures ruling out common bile duct stones in
these patients. Missing out on CBD stones can have disastrous
complications in early postoperative periods, such as cystic duct
stump blowout and jaundice. [11, 12] MRCP was not performed
due to economic restraints in the present study. Identifying co-
morbidities is another important aspect of preoperative prepara-
tion.[12,13]Diabetes mellitus, hypertension, and ischemic heart
disease are the most common comorbidities in gallstone disease
patients. Identifying comorbidities and optimising patients be-
fore surgical intervention help reduce morbidity and prevent
mortality in such patients. [12]
5 (6.67%) patients were converted to open procedures. Rea-
sons for conversion were iatrogenic injury, obscure anatomy
and excessive bleeding. Over time, the conversion rates are de-
creasing due to advancements in technology accompanied by
improvements in surgical techniques concerning laparoscopic
cholecystectomies. [12, 14]
It was also observed that the procedure that needed conver-
sion took far more time laparoscopically before the intraopera-
tive decision to convert to open was taken. The most common
cause for conversion was either a suspected bile duct injury or
difficult anatomy. Excessive bleeding is another important rea-
son for conversion. Converted patients had a longer duration
of hospital stay and were more prone to develop postoperative
complications than those who underwent a successful laparo-
scopic procedure. Bleeding continues to be the main cause of
conversion. It is safe to convert to open if one encounters ex-
cessive bleeding rather than continuing with efforts to control
the bleeding, which may cause more injuries. If damage to the
common bile duct is suspected at the laparoscopic procedure,
the surgeon should immediately convert to open. Bile duct in-
jury identified intraoperatively should be managed based on the
type of injury. [11, 12, 13]
If there is an incomplete transaction without loss of length, a
T-tube can be placed and the rent sutured. However, a biliary
enteric procedure may be required in the complete transaction.
Due to difficult anatomy, the surgeon may not be able to identify
the exact site of injury. In such a situation, it is safe to stop further
dissection and place a drain in the sub-hepatic region to prevent
bile collection. ERCP with stenting in the early postoperative
period helps identify the site of injury and serves as an effective
therapy in case of minor iatrogenic bile duct injuries. [14]
The mean duration of surgery was 46.18 minutes. A shorter
duration of surgery has added to the growing popularity of
laparoscopic surgery. The range of duration varies between 35
to 90 minutes. Cases that exceeded 60 minutes in duration were
associated with conversion.
A multitude of complications can develop after laparoscopic
surgery. The most important complication is delayed presenta-
tion of bile duct injuries. [13, 15] Difficult dissections necessitate
the placement of a drain. If one observes a bile leak in the early
postoperative period, it is necessary to conduct laboratory in-
vestigations and imaging. Laboratory investigations include a
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2022) 6(7):61-65

4. Table 3 Causes for conversion.
Intraoperative causes Number
Iatrogenic Injury 2
Excessive oozing from gall bladder bed not controlled by
topical haemostatic agents
1
Inability to identify the junction of the cystic duct and
common bile duct
2
Table 4 Post-operative complications
Post op complications No. of Patients Percentage (%)
Bile leak (> 100ml/24hrs) 3 4
Fever 4 5.3
Post-op Jaundice 2 2.6
Peritonitis 1 1.3
complete blood count and liver function tests. These may reveal
leucocytosis suggestive of sepsis and raised bilirubin sugges-
tive of bile duct injury. Raised total bilirubin after laparoscopic
surgery may be a cause for concern. There can be multiple
causes for the same. Bile spills due to accidental perforation of
the gallbladder during dissection can be a common cause. This
is due to the transperitoneal absorption of bile. In the event of
bile spillage, it is important to irrigate the local area with warm
saline till the effluent is clear. Any spilt gall stones need to be
meticulously removed. [16]
If the intraoperative dissection was uneventful, the possi-
bility of bile leak could be from the cystic plate, where minor
biliary channels could have been transacted. Such patients re-
quired drainage with observation, and usually, most of these
leaks stop within 48 hours of good supportive care. However, if
hyperbilirubinemia and persistent bile leak continue, an MRCP
is indicated. MRCP helps in identifying the anatomical integrity
of the extrahepatic biliary system. If there is any breach in the
continuity of the bile duct, then stenting is therapeutic. How-
ever, adequate drainage is necessary if MRCP shows complete
loss of bile duct continuity. Percutaneous trans-hepatic biliary
drainage is necessary, accompanied by drain placement in the
sub-hepatic region. This should be followed 12 weeks later by
elaborate imaging. A definitive biliary enteric anastomosis can
be contemplated. Fever may be seen in a few cases during the
early postoperative period. The aetiology of fever can be multi-
factorial. Most common can be the respiratory origin, followed
by local abdominal causes. A good air entry in the lungs without
foreign sounds excludes respiratory causes. Port sites should be
evaluated for surgical site infection, one of the common causes
of fever. Adequate skin preparation and proper scopes sterilisa-
tion a prerequisites for any surgical procedure. Assuming these
variables to be within normal limits, one then needs to focus on
the technique of port placement. The meticulous technique of
port insertion is important in preventing hematoma, especially
in patients with comorbidities. Meticulous closure of the port
site followed by local irrigation of the subcutaneous tissues prior
to skin closure can avoid port site infection. [17]
Bile spillage due to rupture of the gallbladder during surgery
could accumulate in the sub-hepatic region, giving a septic focus.
Sonography can help identify any bile collection and thereby
the need for interventional drainage. In prolonged surgery with
spillage of bile and oozing during surgery, it is advisable to
continue with antibiotics for at least five days. Postoperative
complications seen in the present study were further subdivided
into subgroups, out of which fever was the most commonly
seen in 5.13 % of patients. This was followed by bile leak in
4%, post-operative jaundice in 2.64 %, and a rare complication
of peritonitis in 1.3 % of patients. Out of five patients who
developed postoperative complications, 4 were those in whom
an on-table decision to convert to open was taken. This suggests
that conversion to an open procedure is also associated with
more complications by serious pathology and difficult anatomy.
[13, 16, 17]
The mean duration of hospital stay in patients was 4.34±1.8
days. The majority of patients stayed for less than 5 days. Pa-
tients who converted to open procedures stayed beyond five
days.
The limitations of the present study are that there is no com-
parison between various groups, and the sample size is small.
Hence, a randomised controlled trial is needed to establish the
efficacy of laparoscopic cholecystectomy in acute calculous chole-
cystitis.
Conclusion
Laparoscopic cholecystectomy in acute calculous cholecystitis is
a viable option. Mean operating time decreases the incidence of
intraoperative and postoperative complications. In addition, a
decrease in the incidence of conversion with a short hospital stay
is a promising feature that strongly favours laparoscopic chole-
cystectomy as the standard of care in treating acute calculous
cholecystitis.
Acknowledgements
The authors would like to thank the Dean, D.Y.Patil University
School of Medicine, Navi Mumbai, India, for permission to
publish the study. The authors would also like to thank Parth
Vagholkar for his help in typesetting the manuscript.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2022) 6(7):61-65

5. Funding
Nil.
Conflict of Interest
The authors would like to declare no conflict of interest.
References
1. McArthur P, Cuschieri A, Sells RA, Shields R. Controlled
clinical trial comparing early with interval cholecystectomy
for acute cholecystitis. Br J Surg. 1975 Oct; 62(10):850-2. doi:
10.1002/bjs.1800621025. PMID: 1104043.
2. Koti RS, Davidson CJ, Davidson BR. Surgical management
of acute cholecystitis. Langenbecks Arch Surg. 2015 May;
400(4):403-19. doi: 10.1007/s00423-015-1306-y. Epub 2015
May 14. PMID: 25971374.
3. Borzellino G, de Manzoni G, Ricci F, Castaldini G, Guglielmi
A, Cordiano C. Emergency cholecystostomy and subse-
quent cholecystectomy for acute gallstone cholecystitis
in the elderly. Br J Surg. 1999 Dec; 86(12):1521-5. doi:
10.1046/j.1365-2168.1999.01284.x. PMID: 10594498.
4. Z’graggen K, Metzger A, Birrer S, Klaiber C. Die la-
paroskopische Cholecystektomie als Standardtherapie bei
der akuten Cholecystitis. Eine prospektive Studie [Laparo-
scopic cholecystectomy as standard therapy in acute chole-
cystitis. A prospective study]. Chirurg. 1995 Apr; 66(4):366-
70. German. PMID: 7634948.
5. Suter M, Meyer A. A 10-year experience with the use of
laparoscopic cholecystectomy for acute cholecystitis: is
it safe? Surg Endosc. 2001 Oct; 15(10):1187-92. doi:
10.1007/s004640090098. Epub 2001 Aug 16. PMID:
11727099.
6. Lee SO, Yim SK. [Management of Acute Cholecystitis]. Ko-
rean J Gastroenterol. 2018 May 25; 71(5):264-268. Korean.
doi: 10.4166/kjg.2018.71.5.264. PMID: 29791985.
7. Bagla P, Sarria JC, Riall TS. Management of acute chole-
cystitis. Curr Opin Infect Dis. 2016 Oct; 29(5):508-13. doi:
10.1097/QCO.0000000000000297. PMID: 27429137.
8. Fontes PR, Nectoux M, Eilers RJ, Chem EM, Riedner CE. Is
acute cholecystitis a contraindication for laparoscopic chole-
cystectomy? Int Surg. 1998 Jan-Mar; 83(1):28-30. PMID:
9706512.
9. Al Salamah SM. Outcome of laparoscopic cholecystectomy
in acute cholecystitis. J Coll Physicians Surg Pak. 2005 Jul;
15(7):400-3. PMID: 16197867.
10. Suter M, Meyer A. A 10-year experience with the use of
laparoscopic cholecystectomy for acute cholecystitis: is
it safe? Surg Endosc. 2001 Oct; 15(10):1187-92. doi:
10.1007/s004640090098. Epub 2001 Aug 16. PMID:
11727099.
11. Sato M, Endo K, Harada A, Shijo M. Risk Factors of Postop-
erative Complications in Laparoscopic Cholecystectomy for
Acute Cholecystitis. JSLS. 2020 Oct-Dec; 24(4):e2020.00049.
doi: 10.4293/JSLS.2020.00049. PMID: 33144824; PMCID:
PMC7592957.
12. Hayama S, Ohtaka K, Shoji Y, Ichimura T, Fujita M, Sen-
maru N, Hirano S. Risk Factors for Difficult Laparoscopic
Cholecystectomy in Acute Cholecystitis. JSLS. 2016 Oct-Dec;
20(4):e2016.00065. doi: 10.4293/JSLS.2016.00065. PMID:
27807397; PMCID: PMC5081400.
13. Giger UF, Michel JM, Opitz I, Th Inderbitzin D, Kocher
T, Krähenbühl L; Swiss Association of Laparoscopic and
Thoracoscopic Surgery (SALTS) Study Group. Risk factors
for perioperative complications in patients undergoing la-
paroscopic cholecystectomy: analysis of 22,953 consecutive
cases from the Swiss Association of Laparoscopic and Tho-
racoscopic Surgery database. J Am Coll Surg. 2006 Nov;
203(5):723-8. doi: 10.1016/j.jamcollsurg.2006.07.018. Epub
2006 Sep 20. PMID: 17084335.
14. Mohiuddin K, Nizami S, Fitzgibbons RJ Jr, Watson P,
Memon B, Memon MA. Predicting iatrogenic gall blad-
der perforation during laparoscopic cholecystectomy: a
multivariate logistic regression analysis of risk factors.
ANZ J Surg. 2006 Mar; 76(3):130-2. doi: 10.1111/j.1445-
2197.2006.03669.x. PMID: 16626349.
15. Assaff Y, Matter I, Sabo E, Mogilner JG, Nash E, Abraham-
son J, Eldar S. Laparoscopic cholecystectomy for acute chole-
cystitis and the consequences of gallbladder perforation,
bile spillage, and "loss" of stones. Eur J Surg. 1998 Jun;
164(6):425-31. doi: 10.1080/110241598750004238. PMID:
9696443.
16. Giuliante F, Vellone M, Fianchini M, Nuzzo G. Rischio op-
eratorio della colecistectomia laparoscopica [The surgical
risk of laparoscopic cholecystectomy]. Ann Ital Chir. 1998
Nov-Dec; 69(6):723-9. Italian. PMID: 10213944.
17. Bhandari TR, Khan SA, Jha JL. Prediction of difficult
laparoscopic cholecystectomy: An observational study.
Ann Med Surg (Lond). 2021 Nov 14; 72:103060. doi:
10.1016/j.amsu.2021.103060. PMID: 34815866; PMCID:
PMC8591467.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2022) 6(7):61-65