Operative management of acute cholecystitis

1. Preoperative preparation

• Confirm diagnosis and severity with clinical assessment, blood tests, and ultrasound.
• Resuscitate: IV fluids, analgesia, antiemetic treatment.
• Give perioperative antibiotics when acute infection is suspected.
• Assess for common bile duct stones or cholangitis. If likely, obtain appropriate ductal imaging or perform ERCP before or in coordination with surgery.
• Correct coagulopathy and optimize significant cardiopulmonary, renal, or metabolic illness.
• Obtain informed consent including risks of bleeding, bile leak, bile-duct injury, conversion to open surgery, and subtotal cholecystectomy.

2. Timing

• Early LC during the index admission is preferred for most Grade I and suitable Grade II acute cholecystitis cases.
• Tokyo Guidelines 2018 supports early surgery when the patient can withstand it and an experienced laparoscopic team is available, rather than relying on a strict symptom-duration cutoff. The Tokyo surgical guidance also emphasizes safe operative steps and bailout procedures.
• If the patient is unstable, has uncontrolled organ dysfunction, or is not fit for anaesthesia, gallbladder drainage such as percutaneous cholecystostomy may be used as a bridge or, in selected patients, definitive palliation followed by reassessment for interval cholecystectomy.

3. Standard laparoscopic cholecystectomy: operative outline

1. Anaesthesia and position
   General anaesthesia. Patient supine, then reverse Trendelenburg with slight left tilt to move bowel away from the right upper quadrant.
2. Access and ports
   Establish pneumoperitoneum and place camera and working ports to expose the gallbladder.
3. Initial assessment
   Inspect for adhesions, distension, gangrene, perforation, abscess, or severe inflammation. A tense gallbladder may require controlled decompression to permit grasping.
4. Exposure
   Retract the fundus cephalad and the infundibulum laterally. Divide adhesions cautiously. Open the peritoneum over the gallbladder neck and dissect carefully.
5. Achieve the critical view of safety before clipping or dividing structures
   This requires:
   • clearing fat and fibrous tissue from the hepatocystic triangle;
   • separating the lower one-third of the gallbladder from the liver to expose the cystic plate;
   • seeing only two structures entering the gallbladder, the cystic duct and cystic artery.
   This is the principal safeguard against mistaking the common bile duct for the cystic duct. Fischer's Mastery of Surgery, 8th ed., p. 4570.
6. Control of cystic structures
   Once anatomy is unequivocal, control and divide the cystic artery and cystic duct. Intraoperative cholangiography or another imaging method should be considered when anatomy is unclear, a ductal stone is suspected, or biliary injury is a concern.
7. Separate gallbladder from liver bed
   Dissect the gallbladder from the cystic plate/liver bed using careful energy application, ensuring hemostasis and avoiding thermal injury to the bile duct.
8. Specimen retrieval and closure
   Remove the gallbladder in a retrieval bag, inspect the field for bleeding or bile leak, irrigate selectively, and close port sites. A drain is not routine after an uncomplicated LC, but may be used selectively, especially after a subtotal procedure or concern for leak.

4. Difficult acute cholecystitis: safety principles

• seek assistance from another experienced surgeon;
• use intraoperative cholangiography or other imaging;
• change the dissection strategy, often fundus-first;
• convert to open surgery when needed for exposure or control;
• perform a subtotal cholecystectomy if the critical view cannot be safely obtained.

Conversion to an open operation is not a failure. It is a safety decision, and open conversion alone does not eliminate bile-duct-injury risk.

5. Open cholecystectomy

• safe laparoscopic progression is not possible;
• uncontrolled bleeding or a suspected major bile-duct injury occurs;
• there is severe local destruction, fistula, malignancy concern, or a concomitant open operation.

6. Postoperative care

• Monitor pain, vitals, oral intake, urine output, and signs of bleeding or sepsis.
• Early mobilization, diet advancement as tolerated, and venous-thromboembolism prophylaxis when indicated.
• Investigate fever, jaundice, persistent tachycardia, abdominal pain, or bilious drain output for bile leak, retained duct stone, abscess, or bile-duct injury.
• Histopathology of the specimen is routine.

Key exam points

• Early laparoscopic cholecystectomy is first-line for fit patients with acute calculous cholecystitis.
• The central intraoperative rule is: do not clip or cut until the critical view of safety is achieved.
• If anatomy is unsafe: pause, image, call for help, change approach, convert, or perform subtotal cholecystectomy.
• Cholecystostomy is mainly for patients too high-risk for immediate surgery.

Acute vs chronic cholecystitis

Acute calculous cholecystitis

Chronic cholecystitis

• episodic RUQ or epigastric pain
• often after a fatty meal
• may radiate to the right shoulder or back
• usually no persistent fever or marked inflammatory response

Important distinction

Management summary

• Acute cholecystitis: admit, assess severity and fitness for surgery, provide fluids/analgesia and appropriate antibiotics, and perform early laparoscopic cholecystectomy in suitable patients. For unstable or very high-risk patients, percutaneous gallbladder drainage may be used.
• Chronic cholecystitis: elective laparoscopic cholecystectomy is indicated when symptoms are recurrent or troublesome.