Cholecystectomy is one of the most commonly carried out surgical procedures in the abdomen globally and remains the definitive surgery for the treatment of symptomatic gallstones and their complications.[1] Gallstone disease is a significant health burden in the world and is prevalent at different rates depending on age, gender, ethnicity, and geographical location.[2] Epidemiological data suggest that gallstone disease occurs in about 10-15% of adults in Western populations, with an increasing incidence in some developing countries with a shift towards a Western diet, obesity, metabolic disorders, and ageing of the population.[3] The treatment for gallstones is usually cholecystectomy, which is either done as an open surgery or a minimally invasive laparoscopy.[4] While laparoscopically assisted cholecystectomy is now the preferred approach for uncomplicated gallbladder disease, open cholecystectomy is still relevant for complicated patients and in patients where laparoscopy is contraindicated, or conversion is indicated.[5] Surgical technique may impact recovery, especially recovery of normal gastrointestinal function, an important part of successful surgery.[5]

Gastrointestinal recovery is a multi-faceted process including the recovery of intestinal motility, tolerance of oral feedings, flatus passage, and return to normal bowel movements following surgery.[5] Abdominal surgery can cause temporary gastrointestinal motility dysfunction, known as postoperative ileus, due to inflammatory reactions, anaesthesia, inhibitory neural pathway activation, and opioid use, as well as surgical manipulation.[6] Poor bowel recovery may lead to a bloated tummy, indigestion, nausea, vomiting, longer stay in hospital, and higher healthcare costs.[7] Time to first flatus and first bowel movements are two of the most commonly reported clinical parameters that are useful for assessing the return of intestinal activity.[8] These benefits do not, however, reflect the patient's overall digestive benefit; sometimes patients can be relieved of the symptoms of bloating, abdominal discomfort, altered bowel function, nausea, and food intolerance despite having had their bowel function returned to normal.[9] Therefore, clinical and subjective measures of gastrointestinal recovery are both necessary.

Laparoscopic cholecystectomy is commonly reported to have smaller incisions, less trauma to the abdominal wall, fewer complications in the immediate postoperative period, earlier mobilization, and shorter hospital stays when compared to open cholecystectomy.[10] The benefits of these could help to improve the recovery of gastrointestinal function by lowering surgical stress, inflammatory responses, and postoperative analgesic needs, especially opioid use.[11] Open cholecystectomy, on the other hand, carries with it a bigger cut into the abdomen and more manipulation of tissue, which can lead to more discomfort and longer intestinal recovery time.[12] However, other factors such as pneumoperitoneum during laparoscopy, anaesthetic exposure and perioperative fluid intake, and patient factors can also affect gastrointestinal motility.[12] Hence, laparoscopic surgery could be beneficial in terms of overall recovery after surgery; however, the extent of improvement in the time to first flatus, first bowel movement, and patient-reported digestive symptoms needs to be further clinically assessed.

It is important to point out that postoperative outcomes should not be evaluated only by the traditional surgical parameters like operative time, surgical wound complications, and hospital stay. The return to normal eating patterns, comfortable digestion, and normal bowel function is another significant aspect of recovery. The differences between open and laparoscopic surgery could be especially important in the early post-operative period when gastrointestinal symptoms may impact nutritional intake, patient satisfaction, mobility, and discharge readiness. Moreover, the importance of objective bowel recovery vs subjective digestive symptoms still remains clinically relevant because although flatus may be passed early, it is not necessarily associated with a complete resolution of gastrointestinal symptoms. A comprehensive comparison incorporating these outcomes may therefore provide a more clinically meaningful understanding of the benefits of minimally invasive surgery.

A comparative prospective observational study was conducted at the General Surgery Department, Bolan Medical Complex Hospital, Quetta, Pakistan. The study was conducted for six months from 1st December 2025 to 31st May 2026. It was a study that compared gastrointestinal recovery in patients after open cholecystectomy with those after laparoscopic cholecystectomy. The patients were randomly assigned to the groups based on the surgical procedure that the treating surgical team chose as part of routine clinical management. Time to first flatus, time to first bowel movement, and patient-reported postoperative digestive symptoms were studied.

The sample size was calculated using the OpenEpi online sample size calculator (version 3.01) for comparison of two independent proportions. In a recent randomized clinical study, 67.5% of patients in the laparoscopic surgical technique group had flatus within 24 hours after surgery, compared with 40.0% in the conventional surgical technique group.[13] These proportions were used as reference estimates in calculating sample size since directly comparable recent data for open versus laparoscopic cholecystectomy were limited.  A minimum sample size of roughly 102 patients in each arm (total 204 patients) was calculated for the designed study with a two-sided significance level of 5%, a confidence level of 95%, and a statistical power of 80% and a 1:1 allocation ratio. After allowing for a 10% potential loss to follow-up or incomplete data, the final target sample size was 114 patients, comprising 57 patients in each group.

A non-probability consecutive sampling technique was used to recruit eligible patients. Patients who met the inclusion criteria and who received either open or laparoscopic cholecystectomy in the study period were recruited consecutively until the desired sample size was reached. The surgical approach was divided into two groups for the participants. Group A included patients undergoing open cholecystectomy, while Group B included patients undergoing Laparoscopic cholecystectomy. An equal number of patients was targeted for both groups to facilitate comparison of postoperative gastrointestinal outcomes.

Patients with symptomatic gallstone disease between 18 and 65 years of age at the time of diagnosis, both male and female, and who had undergone elective open or laparoscopic cholecystectomy, were included in the study. Eligible for participation were patients who were medically suitable for either operation, who did not have any pre-existing significant gastrointestinal motility disorder, and who gave informed written consent. Patients were excluded if they had previously had a major surgical operation on the abdomen, or chronic constipation, irritable bowel syndrome, inflammatory bowel disease, intestinal obstruction, or other condition which affected normal gastrointestinal motility. Patients who had emergency cholecystectomy were excluded if they had complicated acute cholecystitis, needed further abdominal surgery, or were converted from laparoscopy to laparotomy. Patients were excluded from the final analysis if they had incomplete postoperative follow-up or if they had no data on gastrointestinal recovery.

Demographic and clinical data were collected on a structured data collection proforma after obtaining informed written consent. Age, sex, BMI, presenting symptoms, medical history, and preoperative clinical characteristics were included as baseline variables. The surgical procedure, time of operation, anaesthetic, and postoperative administration of analgesics were also noted. After surgery, patients were followed to see whether gastrointestinal function was restored. Time to first flatus was measured from the time the surgery was completed until the patient reported the first passage of intestinal gas, in hours. Similarly, the time to first bowel movement was calculated from the completion of surgery until the first postoperative defecation.

A structured symptom assessment questionnaire was used to evaluate digestive symptoms in the patient following surgery at 24, 48, and 72 hours after surgery. The questionnaire assessed abdominal bloating, nausea, vomiting, abdominal discomfort, constipation, and inability to tolerate oral feeding. Symptoms were rated on a five-point Likert scale (0 = none, 4 = very severe). Symptom burden was calculated by adding the scores of the various symptoms; higher scores revealed more digestive discomfort following surgery. Observations were made in a consistent manner in both groups. Patients were followed until their discharge or 72 hours after surgery assessment, whichever came first.

The collected data were entered and analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 26.0. Age, body mass index, time to first flatus, and time to first bowel movement were quantitative variables and reported as mean ± SD. Categorical data such as sex, digestive symptoms, and the relevant clinical characteristics were given as frequencies and percentages. The Shapiro–Wilk test was used to determine the normality of continuous variables. For normally distributed continuous variables, an independent-samples t-test was used for comparison between the two groups. The chi-square test was used to compare categorical variables. Two forty-eight-hour scores of the digestive symptoms were compared between the groups by an appropriate repeated-measures analysis. Age, sex, BMI, operative time, and postoperative opioid use were accounted for in multivariable analysis as appropriate for potential confounding. The p-value was judged at two-sided 0.05.

In total, 114 patients were included in the analysis, consisting of 57 patients undergoing open cholecystectomy and 57 patients undergoing laparoscopic cholecystectomy. The two groups were compared with respect to their baseline demographic and clinical features such as age, gender, BMI, symptom duration, presence of comorbidities, and preoperative abdominal pain. Demographic and clinical characteristics were similar between the groups, with no significant difference in the distribution of the variables (Table 1).

Operative and perisurgical parameters showed a better recovery profile in patients undergoing laparoscopic cholecystectomy. They had a shorter operative time, earlier oral nutrition, and a shorter hospital stay than those who had open cholecystectomy. Post-operative opioid requirement and intraoperative complications were also evaluated for possible differences in peri-operative management and surgical outcomes (Table 2).

In gastrointestinal recovery, the patients who had undergone laparoscopy had a better recovery of bowel function, as shown by the previous comparison. The laparoscopic group had a shorter time for first passage of flatus and first BM compared to the open surgery group. These results indicated that the minimally invasive procedure was correlated with quicker gastrointestinal recovery after surgery (Table 3).

Patient-reported overall digestive symptom burden was evaluated at 24, 48, and 72 hours after surgery. Overall, there was a decrease in digestive symptom severity in both groups during the postoperative assessment period. Compared to open surgery, however, patients who underwent laparoscopic surgery had lower total symptom scores, suggesting better digestive comfort in the early recovery period (Table 4).

Individual digestive symptoms were assessed, and differences were found between the two surgical groups in the extent of abdominal bloating, feeling of unease, nausea, vomiting, abdominal discomfort, constipation, and food intolerance. All these symptoms were assessed at every postoperative time point. Overall, the laparoscopic group showed a more favourable trend of symptom improvement in the first 72 hours after surgery (Table 5).

The proportion of patients experiencing individual digestive symptoms at 72 hours was also compared between the two groups. Bloating, nausea, vomiting, abdominal discomfort, constipation, and food intolerance were assessed. A generally lower frequency of persistent digestive symptoms was observed among patients who underwent laparoscopic cholecystectomy, suggesting better early postoperative digestive recovery compared with the open surgical approach (Table 6).

Table 1. Baseline demographic and clinical characteristics

Table 2. Operative and perioperative characteristics

Table 3. Comparison of postoperative gastrointestinal recovery

Table 4. Patient-reported overall digestive symptom burden

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Table 5. Individual patient-reported digestive symptoms over 72 hours

Table 6. Proportion of patients reporting digestive symptoms at 72 hours

In the present study, the gastrointestinal recovery profile was found to be more favourable in patients who were operated laparoscopically for cholecystectomy than in those who were operated through a laparotomy incision. Patients with laparoscopy had earlier passage of flatus and first BM, indicating a relative improvement in intestinal functions. These results corroborated those of Al Aleem et al. (2026), who performed a prospective observational study on 100 patients and found that patients who underwent laparoscopic cholecystectomy reported significantly better postoperative recovery, less pain, and shorter hospital stays.[14] Likewise, Gul Rukh et al. (2026) in a comparative study of 150 patients admitted for acute cholecystitis found that the duration of hospitalisation, ambulation, and oral intake were shorter in the laparoscopic surgery group.[15] These studies did not consider the same gastrointestinal endpoints, but their results were consistent with the relatively good recovery pattern seen in the present study.

This is likely due to the reduced trauma to the abdominal wall and to smaller manipulation of tissues in the laparoscopic group, which is the reason for this earlier recovery of bowel function. In contrast, open surgery usually makes a larger incision and increases the stress on the patient, which could increase the chances of postoperative discomfort and slow down the patient's mobility. The same was seen by Iqbal et al. (2024), who compared 113 patients who underwent open and laparoscopic cholecystectomy and found that the operative time was shorter in the laparoscopic group, as well as the duration of hospitalization.[16] Laparoscopic surgery was also found to reduce the length of hospital stay and postoperative pain by significantly less than the open surgery group in a study of complicated gallstone disease by Shakoor et al. (2024).[17] These results are similar to our study, in which a better recovery profile was observed in the early days, although neither of these studies measured time to first flatus or defecation as their primary outcome measure.

Recovery of gastrointestinal function was also confirmed by studies concerned with postoperative bowel function after laparoscopic cholecystectomy. Sun et al. (2025) commented on the nursing of enhanced recovery after surgery of the patients who underwent laparoscopic cholecystectomy and achieved significantly earlier flatus passage and defecation in the enhanced recovery group than in the conventional care group.[18] Likewise, a 2025 study comparing the rapid recovery nursing of acute calculus cholecystitis patients with unassisted care found a shorter time to first flatus, bowel movement, and oral feeding after the rapid recovery nursing procedure.[19] These studies did not look at open versus laparoscopic surgery, but they did emphasize the role of perioperative management in influencing gastrointestinal recovery.

In terms of digestive symptoms after the surgery, the findings from the present study showed a decrease in the overall score of the symptoms in the laparoscopic group at 24, 48, and 72 hours. Most participants reported improvements in abdominal bloating, nausea, vomiting, abdominal discomfort, constipation, and food intolerance during the observation period. This pattern had clinical significance as recovery after surgery of the digestive system went beyond just bowel movements. In a 2024 multicentre retrospective study of 1286 patients with early postoperative abdominal distension after laparoscopic cholecystectomy, it was found that early postoperative abdominal distension was more completely resolved and that time to first flatus was shorter with simethicone compared to no simethicone.[20] In addition, a study from 2025 found that gastrointestinal issues such as bloating and changes in bowel movements may occur after laparoscopic cholecystectomy.[21] The results confirmed the significance of evaluating subjective symptoms of digestion in addition to the conventional assessment of bowel recovery.

The more extensive comparative data also confirmed that the laparoscopic surgery offered benefits in postoperative recovery. Toheed et al. (2023) conducted a prospective observational study of 120 patients undergoing laparoscopy or open surgery for the abdomen in PIMS Islamabad and Bolan Medical Complex Hospital, Quetta, and found that patients in the laparoscopy group had less postoperative pain, earlier ambulation, shorter hospital stays, and fewer complications. Their study was not limited to cholecystectomy, but involved other abdominal surgical procedures to provide evidence from a similar health care context.[22] Khalid et al. (2023), in a retrospective comparison of 80 patients undergoing open or laparoscopic cholecystectomy at Lahore General Hospital, also evaluated postoperative complications and demonstrated the importance of considering surgical approach when assessing postoperative outcomes.[23]

Further evidence from the region has confirmed this comparison more recently. Rashid et al. (2026), in a retrospective study of 320 patients from North Kashmir, reported shorter operative duration, lower analgesic requirements, fewer complications, and shorter hospital stays following laparoscopic cholecystectomy. The current study's recovery pattern was similar to that of these findings, which were generally favourable. However, differences in patient selection, surgical indications, perioperative protocols, and outcome definitions should be considered when comparing results across studies.

LIMITATIONS

There were some limitations to the present study. First, it was a single tertiary care hospital, which may restrict the generalizability of the results to other health care facilities. Secondly, the non-probability consecutive sampling technique could have resulted in selection bias. Third, observational study design prevented randomization of patients to surgical groups, and differences in baseline clinical characteristics or surgical indications may have affected postoperative outcomes. In addition, digestive symptoms were also scored using a structured questionnaire, the subjective report of which could have influenced the result. The relatively brief follow-up time of 72 hours also did not allow persistence of digestive symptoms to be evaluated, and long-term gastrointestinal function was not studied. Lastly, the differences in postoperative analgesics, feeding schedule, and surgery-related care might have impacted gastrointestinal recovery.

Laparoscopic cholecystectomy showed a better early postoperative gastrointestinal recovery profile compared with open cholecystectomy. Patients who had been treated with laparoscopy showed earlier defecation and flatus, lower scores for digestive symptoms, and an overall better recovery pattern after surgery. The results suggest that minimally invasive surgery can have potential benefits for early recovery of the gastrointestinal system. Larger, multicenter studies with standardized perioperative protocols and longer follow-up, though, are recommended to confirm these findings.

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