Timing of laparoscopic cholecystectomy in acute cholecystitis

Timing of laparoscopic cholecystectomy in

acute cholecystitis
S Cheema, AE Brannigan, S Johnson, PV Delaney, PA Grace
Department of Surgery, Mid-Western Regional Hospital, and The National Institute for Health Sciences, University of
Limerick, Ireland

Abstract
Background Laparoscopic cholecystectomy is associated with an increased conversion rate in acute cholecystitis.
Aim To review the operative management of symptomatic cholelithiasis with particular reference to conversion rates
and morbidity for laparoscopic cholecystectomy for acute cholecystitis.
Methods Patients undergoing cholecystectomy between January 1994 and December 1998 were recruited.
Demographic details, diagnosis, duration of symptoms, treatment, outcome, post-operative stay and complications
were recorded.
Results Complete data were available on 482 patients (84%). Laparoscopic cholecystectomy was attempted in 120
of 132 patients (91%) with acute cholecystitis and 329 of 350 patients (94%) with non-acute gallbladder disease.
Conversion rates were 27% (33/120) and 6.7% (22/329) for acute and non-acute gallbladder disease, respectively
(p<0.001 χ2 test). Relating the interval from onset of symptoms to surgery, conversion rates for acute cholecystitis
were: <3 days, 5/17 (29%); 4 to 42 days, 14/59 (23%) and >42 days, 14/44 (31%). There were three bile duct injuries,
two in the delayed (>45 days) acute group and one in the non-acute group.
Conclusion Early laparoscopic cholecystectomy is the treatment of choice for acute cholecystitis, but is associated
with a high conversion rate independent of the timing of surgery.

Introduction used appro p r i a t e l y.

Laparoscopic cholecystectomy has become the standard
treatment for gallstones.1,3 Its advantages over open
cholecystectomy include reduced discomfort and hospital stay
and an economic benefit of an earlier re t u rn to work.1,8,9 The ro l e
of laparoscopic cholecystectomy in the management of patients
with acute cholecystitis is controversial. It has been associated
with considerable morbidity and the reported conversion rate is
higher than that reported for laparoscopic cholecystectomy for
non-acute cholecystitis.1-4,9,11 The ideal timing of surgery in acute
cholecystitis remains undefined. Recent studies have suggested
that early laparoscopic intervention decreases conversion rates
compared to delayed surgery.4-7,10
The aim of this study was to review the management of
symptomatic cholelithiasis with special emphasis on the
management of acute cholecystitis and the timing of laparoscopic
cholecystectomy.
Patients and methods
The re c o rds of patients undergoing cholecystectomy at the Mid-
Western Regional Hospital from January 1994 to December
1998 inclusive were reviewed. Data on demographic details,
diagnosis, duration of symptoms, treatment, outcome, post-
operative stay and complications were re c o rded. A subgroup of
patients with acute cholecystitis was identified based on clinical
p resentation, laboratory and radiological investigations, operative
findings and histological analysis. The diagnostic criteria utilised
for acute cholecystitis are shown in Table 1. Data were recorded
on a database (Access 97; Microsoft, Seattle, Washington, USA)
allowing for diff e rent analyses. Statistical analysis was performed
using SigmaStat™ for Windows, version 2.0 (Jendal Scientific
Corporation USA) and parametric and non-parametric tests were
Patients were divided into the following four groups (see
F i g u re 1): acute cholecystitis (n=132); chronic
cholecystitis/biliary colic (n=292); jaundice secondary to
gallstones (n=32); and pancreatitis (n=26). Patients with non-
acute gallbladder disease were grouped together and re f e rred to
as non-acute gallbladder disease for analysis in this paper. Patients
with acute cholecystitis were divided, depending on the duration
of symptoms prior to surgery, into one of the following thre e
groups: symptoms for <3 days; symptoms for 4 to 42 days; and
symptoms for >42 days. These groups were analysed to
specifically determine the optimum timing for laparoscopic
cholecystectomy in acute cholecystitis.
Results
A total of 572 cholecystectomies were perf o rmed during the five-
year period. Complete data were available on 482 patients (84%).
The medical re c o rds of the remaining 16% of patients were not
available or incomplete. The male:female ratio was 355:127, and
the mean female age was significantly younger than that of the
male patients (47.3±16.5 years vs 57.8±13.2 years [p<0.001,
student t-test]).
The diagnosis of non-acute gallbladder disease was made in
350 patients (73%). Of these, 292 had chronic
cholecystitis/biliary colic (83%), 26 had pancreatitis (7%) and 32
had jaundice (9%). The diagnosis of acute cholecystitis was made
in 132 patients (27%).
Operations
The pro c e d u res perf o rmed are summarised in Table 2. Thirty-
t h ree primary open cholecystectomies were performed for
common bile duct (CBD) stones (n=5), multiple pre v i o u s
abdominal pro c e d u res (n=8), associated second pro c e d u re (n=4),

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 S Cheema et al

Study groups
Cholecystectomy Performed n=572

Complete Data n = 482

Acute cholecystitis (n=132) Non-acute gallbladder disease

Symptom duration (Days) Clinical presentation

<3 4-42 <42 Biliary colic Obstructive Pancreatitis

n=17 n=59 n=44 n=292 jaundice n=32 n=26

Figure 1. Laparoscopic cholecystectomy was attempted on 120 patients with acute cholecystitis. They were divided into three
groups according to symptom duration prior to cholecystectomy: <3 days; 4-42 days; and >42 days. The conversion rate to open
cholecystectomy for each group was 29%, 24% and 32%, respectively.

Table 1. Criteria for diagnosis of acute cholecystitis Conversion rates and reasons
The overall rate of conversion from laparoscopic to open
cholecystectomy was 12%. The reasons for conversion are
1. Acute presentation with right upper quadrant pain
summarised in Table 3. Unclear anatomy (n=22), difficulty in
2. Raised white cell count dissection of calots triangle (n=13) and bleeding n=10 were the
3. Gallbladder wall thickening and tenderness main causes of conversion to an open pro c e d u re .
on ultrasonogram Patients with acute cholecystitis who had attempted
l a p a roscopic cholecystectomy were divided into three gro u p s
4. Peroperative finding of acute cholecystitis based on the time between the onset of symptoms and
5. Histological evidence of acute cholecystitis cholecystectomy. The groups were onset of symptoms <3 days
(n=17), between 4 to 42 days (n=59) and >42 days (n=44). The
conversion rates of these three groups were compared to identify
the optimal timing of surgical intervention in acute cholecystitis.
Table 2. Procedures performed in patients with Results are summarised in Table 4 and Figure 1.
symptomatic cholelithiasis Conversion rates for the three groups were 29%, 23% and 31%
respectively, indicating that conversion rates are independent of
Procedure Acute Non-acute Total
timing of laparoscopic surgery.5,6
cholecystitis GB disease

Primary OC 12 21 33 Post-operative hospital stay

Post-operative hospital stay was recorded for all patients and the
Attempted LC 120 329 449 results are summarised in Table 5. Postoperative stay (days) for
Successful LC (%) 87 (73) *307 (93) 394 (87) the intent-to-treat laparoscopic groups was significantly less
Total 132 350 482 compared to primary open cholecystectomy for acute
cholecystitis (5.0±4.2 vs 9.3±6.2 days) for non-acute gallbladder
disease (3.6±3.3 vs 11.9±10 days) and for all patients (4.0±3.6 vs
*p<0.001 versus acute cholecystitis. 11.1±8.9 days) (p<0.01 Mann-Whitney rank sum test). There was
OC, open cholecystectomy; LC, laparoscopic a statistically significant diff e rence in post-operative stay between
successful and unsuccessful laparoscopic cholecystectomy for both
cholecystectomy; GB, gallbladder.
acute cholecystitis (3.6±2.4 vs 8.5±5.5 days) and non-acute
gallbladder disease (3.1±2.6 vs 7.2±3.8 days) (p<0.001 Mann-
Whitney rank sum test).
gallbladder mass (n=8), unclear diagnosis (n=3) and unspecified There was no statistical diff e rence between post-operative stay
(n=8). Laparoscopic cholecystectomy was attempted in 329 of for successful laparoscopic cholecystectomy for acute cholecystitis
350 patients (94%) with non-acute gallbladder disease and was (3.6±2.4 days) compared to non-acute gallbladder disease
successful in 307 of these (93%). (3.1±2.6 days) (p=0.06 Mann-Whitney rank sum test). Similarly,
In comparison, laparoscopic cholecystectomy was attempted in there was no statistically significant difference between
120 of 132 patients (90%) with acute cholecystitis and was unsuccessful laparoscopic cholecystectomy for acute cholecystitis
successful in only 87 patients (73%) (p<0.001 χ2 test vs non-acute (8.5±5.5 days) and non-acute gallbladder disease (7.2±3.8 days)
GB disease. (p=0.25 Mann-Whitney rank sum test).

Irish Journal of Medical Science • Volume 172 • Number 3 129

Timing of laparoscopic cholecystectomy in acute cholecystitis

Table 3. Reasons for conversion from laparoscopic to open cholecystectomy

Acute cholecystitis (n=33) Non-acute GB disease (n=22) Total (n=55)

Unclear anatomy 14 (42%) 8 (36%) 22 (40%)

Difficult dissection 9 (27%) 4 (18%) 13(24%)
Bleeding 7 (21%) 3 (14%) 10 (18%)
CBD injury 2 (6%) 1 (5%) 3 (5%)
Equipment failure 0 (0%) 1 (5%) 1 (2%)
Unspecified 1 (3%)* 5 (23%) 6 (11%)

CBD, common bile duct. *p<0.01 χ2 test versus non-acute GB disease.

Table 4. Timing of surgery in acute cholecystitis injuries remain well at 6 and 14 months follow-up, respectively.
The third patient is well at 36 months post repair but re q u i re s
Duration of symptoms n=120 (%) Conversion intermittent dilatation of an anastomotic stricture (see Table 6).
to OC
<3 days 17 (14%) 5 (29%) Discussion
4 to 45 days 59 (49%) 14 (23%) In the last decade, laparoscopic surg e ry has become the gold
s t a n d a rd for the management of symptomatic gallbladder
>45 days 44 (37%) 14 (31%)
disease but considerable debate surrounds the role of minimally
Total 120 (100%) 33 (27%) invasive surg e ry in the management of acute cholecystitis. 1,4,6
This condition was historically considered a contraindication to
OC = open cholecystectomy. l a p a roscopic cholecystectomy 1,6 and its role re m a i n s
controversial.3,4,6 C o n t roversy relates to the primary appro a c h
for cholecystectomy, the higher complication rate and the
Table 5. Post-operative stay following cholecystectomy timing of laparoscopic surg e ry in patients with acute
cholecystitis. Increasing experience in minimally invasive
Procedure n=482 Days±SD s u rg e ry in recent years has led to the application of laparoscopic
cholecystectomy to patients with acute cholecystitis. This paper
Acute cholecystitis re p resents a five-year audit of the management of patients with
cholelithiasis in one institution and addresses the role of
Primary open cholecystectomy 12 9.3±6.2
laparoscopic cholecystectomy in the management of patients
Intent-to-treat laparoscopic 120 †5.0±4.2 with acute cholecystitis.
Successful laparoscopic The results of this study are consistent with recently
cholecystectomy 87 3.6±2.4 published studies 2,4,6,11 suggesting that the laparo s c o p i c
Unsuccessful laparoscopic approach is successful in the majority of patients with acute
cholecystectomy 33 *8.5±5.5 cholecystitis although it is associate d with significantly higher
Non-acute GB disease conversion (27% vs 7%) and complication rates (19% vs 8%)
Primary open cholecystectomy 21 11.9±10.0 when compared to non-acute gallbladder surg e ry. The higher
Intent-to-treat laparoscopic 329 †3.6±3.3 conversion rate among patients with acute cholecystitis in this
study as in others related to technical difficulty and lack of
Successful laparoscopic
anatomical clarity as a result of adhesions, distortion of tissue
cholecystectomy 307 3.1±2.6 planes and bleeding.6,12,13 In this study, the conversion rate to
Unsuccessful laparoscopic open procedure of 25% compares well with the re p o rted series
cholecystectomy 22 *7.2±3.8 of 15-38%.3,4,6,11
There is a significantly increased operative risk of both major
*p<0.001 vs successful laparoscopic cholecystectomy and minor complications associate d with acute cholecystitis.
†p<0.01 vs primary open cholecystectomy CBD injury is the main risk during laparoscopic surgery for
acute cases. It is mainly related to difficulty in identifying
anatomy and is more likely to take place in delayed surg e ry for
Common bile duct injuries acute cholecystitis.2,5,6,12,13 In our series, there were two CBD
T h e re were three (0.6%) common bile duct (CBD) injuries, all of injuries in patients with acute cholecystitis and both occurred in
which occurred in patients undergoing laparoscopic the group undergoing surg e ry after 42 days. This appears to be
cholecystectomy. Two were identified perioperatively and one was a very high rate of CBD injury (2%) but, when considered in
diagnosed postoperatively. Two occurred in patients with acute the context of the entire series, it is within published limits
cholecystitis undergoing surgery over 42 days following diagnosis (0.6%). Five patients developed a bile leak and one a deep
and the third occurred during cholecystectomy for non-acute venous thrombosis that resulted in pulmonar y embolisation
disease. despite prophylactic measures. There were no perioperative
All three injuries were re p a i red following conversion to an open deaths in this series.
p ro c e d u re. Two of the injuries were relatively minor and were This study describes the benefit of successful laparoscopic
re p a i red over a t-tube. The third was a major duct injury requiring s u rg e ry over primar y open and converted cholecystectomy in
a hepatico-jejunostomy. Both patients with the minor duct t e rms of length of post-operative stay as pre v i o u s l y

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 S Cheema et al

Table 6. Complications

Complication Acute cholecystitis Non-acute GB disease Total

CBD injury 2 1 3
Wound complications 5 1 6
Chest infection 5 4 9
DVT/PE 1 0 1
Post-operative jaundice 3 4 7
Bile leak 2 3 5
Bleeding/transfusion 3 4 7
Others 2 9 11
Total 23a 26 49

*p<0.001 versus non-acute cholecystitis

reported. 1,2,4,6 The ideal timing of laparoscopic cholecystectomy
in patients with acute cholecystitis remains controversial.1,3,4,6 In
this study, we reviewed our results in an attempt to identify the
best timing for s u rgical intervention in acute cholecystitis. It has
been suggested that early laparoscopic cholecystectomy is
associated with a lower conversion rate than delayed
cholecystectomy.3,7,14 Our results show no significant difference
in conversion rates over time which is consistent with the results
of Lo et al5 and Lai et al.4 They also noted an incre a s e d
complication rate with delayed laparoscopic cholecystectomy,
which is consistent with our observation of two bile duct injuries
within those undergoing delayed surg e ry for acute cholecystitis.
Difficulty in early laparoscopic cholecystectomy is due to
oedema and increased vascularity with increased bleeding.
Delayed laparoscopic cholecystectomy is associated with
adhesions and fibro s i s .2,3,5,6,12,13 Early laparoscopic surgery would
have the advantage of single admission treatment, prevention of
re c u rrent symptoms/admission, low cost, social benefits and
d e c reased complications rate.5
We conclude that laparoscopic surgery is the treatment of
choice for both acute and chronic cholecystitis and advocate
early laparoscopic surgery for acute cholecystitis, as it is not
associated with an increased conversion rate, avoids recurre n t
attacks of pancreatitis and biliary colic, avoids repeated
admission and all the related social sequelae in a pre d o m i n a n t l y
young, otherwise healthy population.
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Correspondence to: Professor PA Grace, Professor of Surgical
Science, Department of Surgery, Mid-Western Regional Hospital,
Dooradoyle, Limerick. Email: pagrace@eirc o m . n e t

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