Acute calculous cholecystitis is one of the most frequent causes of emergency abdominal surgery worldwide and represents a major complication of gallstone disease. Contemporary guidelines increasingly support early surgical management, with laparoscopic cholecystectomy (LC) adopted broadly as the preferred approach when feasible [1-3]. Meta-analytic data and recent systematic reviews report that LC is associated with shorter hospital stay, reduced postoperative wound infection and overall lower morbidity compared with open cholecystectomy (OC), while maintaining comparable rates of major biliary complications in appropriately selected patients [1,4].

Despite these advantages, LC in the acute setting carries a recognized risk of conversion to an open procedure and of procedure-related complications when dense inflammation, gangrene or pericholecystic abscesses are present. Several cohort studies have identified predictors of conversion and adverse outcomes — notably advanced age, markedly elevated inflammatory markers (e.g., C-reactive protein), diabetes and gangrenous change — which must be considered when planning the operative strategy [4-6]. Early randomized data and subsequent trials have suggested that, for many patients with acute or gangrenous cholecystitis, LC can be performed safely with outcomes similar or superior to open surgery when experienced laparoscopic surgeons and appropriate intraoperative safety strategies are employed [5].

Guideline updates (including the Tokyo Guidelines 2018 and the WSES 2020 recommendations) therefore recommend that LC be considered the first-line operative option for most patients with acute calculous cholecystitis, reserving OC or bailout strategies (conversion, subtotal cholecystectomy) for cases in which anatomy is hostile or patient factors preclude safe laparoscopic dissection [2,3]. Nonetheless, heterogeneity in patient presentation, surgical experience and institutional resources means that direct, contemporary comparisons of perioperative parameters and patient-centered outcomes between LC and OC remain important to inform local practice. Accordingly, this study was undertaken to compare intraoperative metrics, postoperative morbidity and recovery parameters between laparoscopic and open cholecystectomy in patients presenting with acute calculous cholecystitis.

This was a prospective, comparative, observational study conducted at an hospital. The study was designed to evaluate the clinical outcomes, perioperative parameters, and complications associated with laparoscopic versus open cholecystectomy in patients presenting with acute calculous cholecystitis.

Sample Size and Study Population: Based on previous studies and an expected difference in postoperative complication rates between laparoscopic and open cholecystectomy of approximately 20%, with a power of 80% and α = 0.05, the minimum required sample size was calculated to be 60 patients per group. To account for possible dropouts, a total of 140 patients were enrolled and equally allocated to either the laparoscopic cholecystectomy group (n=70) or the open cholecystectomy group (n=70).

Inclusion Criteria: Patients fulfilling all of the following criteria were included in the study:

• Age 18–70 years.
• Clinical diagnosis of acute calculous cholecystitis based on the Tokyo Guidelines 2018, including right upper quadrant pain, tenderness, and supportive laboratory/imaging findings.
• Fit for general anesthesia as per ASA Physical Status I–III.

Exclusion Criteria: Patients with any of the following were excluded:

• Gallbladder perforation or generalized peritonitis.
• Previous upper abdominal surgery precluding laparoscopic access.
• Severe cardiopulmonary comorbidities (ASA IV–V).
• Coagulopathy or immunosuppression.
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Preoperative Assessment: All patients underwent detailed clinical examination, routine hematological investigations (complete blood count, liver function tests, coagulation profile), and imaging with abdominal ultrasonography. In selected cases, contrast-enhanced CT of the abdomen was performed for complicated presentations.

Surgical Procedure

• Laparoscopic Cholecystectomy (LC): Standard four-port technique under general anesthesia. Pneumoperitoneum was established with CO₂ to 12–14 mmHg. The cystic duct and artery were identified, clipped, and divided. Gallbladder was dissected from the liver bed using electrocautery and retrieved through the umbilical port.
• Open Cholecystectomy (OC): Right subcostal (Kocher) incision was used. The gallbladder was dissected from the liver bed, and cystic structures were ligated. Hemostasis was ensured, and the incision closed in layers with a drain left as indicated.

Postoperative Care: All patients received standard postoperative analgesia and antibiotic prophylaxis. Early mobilization and oral intake were encouraged as tolerated. Postoperative complications such as wound infection, bile leak, bleeding, and pulmonary complications were recorded. Length of hospital stay and time to return to normal activity were noted.

Outcome Measures: Primary outcomes included operative time, intraoperative blood loss, postoperative complications, and length of hospital stay. Secondary outcomes included time to return to normal activity and patient satisfaction.

Statistical Analysis: Data were entered into Microsoft Excel and analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation and compared using the Student’s t-test. Categorical variables were expressed as frequencies and percentages and analyzed using the Chi-square test. A p-value <0.05 was considered statistically significant.

A total of 140 patients with acute calculous cholecystitis were included in the study, with 70 patients each in the laparoscopic and open cholecystectomy groups. The demographic characteristics, including age, sex distribution, body mass index, and ASA physical status, were comparable between the two groups (p>0.05 for all) (Table 1).

Table 1: Demographic Characteristics of Patients

Table 2: Intraoperative Parameters

The mean operative time was significantly shorter in the laparoscopic group (65.4 ± 12.8 minutes) compared to the open group (85.7 ± 15.6 minutes, p<0.001). Estimated blood loss was also significantly lower in patients undergoing laparoscopic cholecystectomy (50.3 ± 18.7 mL vs. 150.6 ± 40.2 mL; p<0.001). Conversion to open surgery was required in 5 patients (7.1%) in the laparoscopic group due to dense adhesions or unclear anatomy. Intraoperative complications were infrequent and comparable between the two groups (2.8% vs. 5.7%; p=0.40) (Table 2, Figure 1).

Table 3: Postoperative Outcomes

Postoperative pain, measured using the Visual Analog Scale at 24 hours, was significantly lower in the laparoscopic group (3.2 ± 1.1) than in the open surgery group (5.8 ± 1.4, p<0.001). Early ambulation was achieved faster in the laparoscopic group (12.5 ± 3.6 hours) compared to the open group (24.7 ± 6.2 hours, p<0.001). The mean hospital stay was significantly reduced for laparoscopic patients (2.8 ± 1.2 days) relative to open cholecystectomy (5.1 ± 1.5 days, p<0.001). Wound infection occurred in 1.4% of laparoscopic cases and 8.6% of open cases (p=0.05), while bile leak and pulmonary complications were rare in both groups. Patients undergoing laparoscopic surgery returned to normal activity earlier (7.2 ± 2.1 days) than those undergoing open surgery (14.5 ± 3.4 days; p<0.001) (Table 3).   

Several recent meta-analyses and systematic reviews have shown that LC for acute cholecystitis is associated with reduced hospital stay, lower wound infection rates and faster postoperative recovery compared with OC, while maintaining comparable rates of major biliary complications when performed by experienced teams [1,7]. Our results—particularly the shorter length of stay (2.8 ± 1.2 days vs. 5.1 ± 1.5 days) and reduced wound infection—align closely with these pooled outcomes and reinforce the advantages of a minimally invasive approach in appropriate patients.

Estimated blood loss in our LC cohort was substantially lower than in the OC group (50.3 ± 18.7 mL vs. 150.6 ± 40.2 mL), a difference that mirrors findings from both cohort studies and pooled analyses which report reduced intraoperative bleeding with laparoscopic techniques [8,9]. Reduced blood loss likely contributes to faster recovery and lower perioperative morbidity, and is a consistent technical advantage of the laparoscopic approach when safe dissection in Calot’s triangle is achievable.

Conversion from LC to OC remains an important consideration. Our conversion rate of 7.1% lies within the range reported in recent multicenter series (commonly 3–12%), though rates vary depending on timing of surgery (early versus delayed), severity of inflammation, patient comorbidity, and surgeon experience [9]. Contemporary predictive models and nomograms aim to identify patients at higher risk of conversion—using variables such as advanced age, elevated inflammatory markers (WBC, CRP), gallbladder wall thickening, and imaging features—to improve operative planning and informed consent. Such tools have shown promising external validation and may help reduce intraoperative uncertainty and complications by guiding case selection or early adoption of bailout strategies [10,11].

Postoperative pain and early mobilization are patient-centered outcomes of high clinical relevance. The significantly lower VAS scores at 24 hours and earlier ambulation observed in our LC group reflect the minimally invasive nature of the procedure and are consistent with randomized and observational literature documenting less postoperative pain and quicker functional recovery after LC compared with OC [10,11]. Earlier return to activity (mean 7.2 ± 2.1 days for LC) also carries implications for patient satisfaction and socioeconomic factors such as earlier return to work.

Wound infection remains more frequent after open procedures, as demonstrated both in our data (8.6% OC vs. 1.4% LC) and in multiple recent surgical series and comparative analyses [7,10]. This difference is biologically plausible given the larger incision and greater tissue exposure inherent in the open technique; it also supports strategies that prioritize laparoscopic access when feasible and safe.

While the benefits of LC are evident, it is important to emphasize safety considerations. Acute cholecystitis may present with severe inflammation, gangrene, or distorted anatomy, and in such settings the surgeon must be prepared to convert to open approach or perform bailout procedures (subtotal cholecystectomy) to avoid major bile duct injury. Recent guideline updates and expert reviews recommend early LC in most cases but underscore the importance of surgeon judgment, use of intraoperative safety steps, and availability of senior laparoscopic expertise for challenging cases [3,12].

This study has limitations. It was a single-center, non-blinded comparative study; although groups were comparable at baseline, unmeasured confounding cannot be excluded. Operative time and intraoperative blood loss may be influenced by surgeon experience and case complexity; while we accounted for common clinical exclusions, some selection bias may persist. Finally, the follow-up period focused on early perioperative outcomes; longer-term outcomes such as incisional hernia rates and quality-of-life indices were not assessed.

Laparoscopic cholecystectomy demonstrated clear advantages over open cholecystectomy in the management of acute calculous cholecystitis. It was associated with reduced intraoperative blood loss, less postoperative pain, shorter hospitalization, and faster return to daily activities, without compromising safety. Although a small proportion of cases required conversion to the open approach due to difficult anatomy or adhesions, overall outcomes strongly support laparoscopic surgery as the preferred technique for most patients with acute calculous cholecystitis.

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