Acute calculous cholecystitis is one of the most frequent surgical emergencies and results from persistent obstruction of the cystic duct, followed by gallbladder distension, inflammation and, in advanced cases, ischaemia, necrosis or perforation. Laparoscopic cholecystectomy is the definitive treatment, but the timing of surgery has historically varied between index-admission operation and an interval procedure after conservative treatment. Contemporary guidelines favour early laparoscopic cholecystectomy whenever it can be performed safely by an experienced team. The 2020 World Society of Emergency Surgery guidelines identify early laparoscopic cholecystectomy as the standard of care whenever feasible, including in many higher-risk subgroups. Tokyo Guidelines 2018 similarly broadened the indication for laparoscopic management while emphasizing severity assessment, critical-view-of-safety principles and appropriate bailout strategies [1-4]. Despite this evidence, delayed surgery remains common in centres facing late presentation, limited emergency theatre availability, anaesthetic constraints or concerns regarding difficult dissection during active inflammation. The delayed strategy may permit resolution of acute oedema, but exposes patients to recurrent biliary events, repeat admission and a longer cumulative treatment pathway. The present study compared early and delayed laparoscopic cholecystectomy with emphasis on operative difficulty, conversion, complications and total hospital stay. Literature survey Randomized trials and meta-analyses have generally shown that early laparoscopic cholecystectomy is not associated with a clinically important increase in bile duct injury, conversion or overall morbidity, and consistently shortens total hospital stay [5-11]. The multicentre ACDC trial demonstrated the clinical and economic advantages of surgery during the acute admission [8]. Earlier randomized studies by Lo et al. and Johansson et al. also found comparable safety with a shorter overall treatment period in early groups [6,7]. The clinical question has therefore shifted from whether early surgery is safe to how it can be delivered safely. Modern recommendations stress structured assessment, attainment of the critical view of safety, judicious use of intraoperative imaging, and early adoption of subtotal cholecystectomy or conversion when anatomy cannot be defined [2-4,12]. Problem definition and objectives In many hospitals, patients with acute calculous cholecystitis are still initially treated with antibiotics and scheduled for interval cholecystectomy. This approach can create recurrent attacks and duplicate hospital use. The primary objective was to compare total hospital stay, conversion to open surgery and postoperative complications between early and delayed laparoscopic cholecystectomy. Secondary objectives were to compare operative duration, difficult operative findings, drain use, readmission before definitive surgery and mortality.

Study design and setting This hospital-based prospective comparative study was designed in the Department of General Surgery at Vilasrao Deshmukh Government Medical College, Latur, Maharashtra, India over 2 Years. A total of 100 consecutive eligible patients were included, with 50 patients in each treatment group. Eligibility criteria Adults aged 18-75 years with acute calculous cholecystitis diagnosed using compatible local inflammatory features, systemic inflammatory response and ultrasonographic evidence were eligible. Grade I and Grade II disease under Tokyo Guidelines criteria was included. Patients with Grade III disease or uncontrolled organ dysfunction, acute cholangitis, gallstone pancreatitis, choledocholithiasis requiring duct clearance, suspected gallbladder malignancy, pregnancy, previous upper abdominal surgery precluding laparoscopy, or inability to provide consent were excluded. Treatment groups The early group underwent laparoscopic cholecystectomy during the index admission, preferably within 72 hours of admission and within seven days of symptom onset. The delayed group received bowel rest as required, intravenous fluids, analgesia and antibiotics, followed by elective laparoscopic cholecystectomy 6-8 weeks later after clinical resolution. Recurrent pain, fever, jaundice or readmission during the waiting interval was recorded. Operative technique All procedures were performed under general anaesthesia using a standard four-port technique. Pneumoperitoneum was established through an open or closed approach according to surgeon preference. After decompression of a tense gallbladder when required, adhesions were released by blunt and sharp dissection. Dissection began in the hepatocystic triangle with the objective of obtaining the critical view of safety: clearance of fibrofatty tissue, separation of the lower third of the gallbladder from the cystic plate, and identification of only two structures entering the gallbladder before division. When the critical view could not be obtained because of dense inflammation, gangrene, bleeding or frozen anatomy, dissection was stopped and a bailout strategy was selected. Options included fundus-first dissection, subtotal cholecystectomy, or conversion to open surgery. The cystic artery and duct were clipped and divided when safely defined. The gallbladder was removed in a retrieval bag, haemostasis and bile leakage were checked, and a subhepatic drain was placed selectively. Outcomes and definitions Operative time was measured from skin incision to completion of skin closure. Conversion was defined as any procedure requiring formal laparotomy to complete cholecystectomy or control a complication. Postoperative complications included surgical-site infection, bile leak, intra-abdominal collection, respiratory complication and other Clavien-Dindo Grade II or higher events. Total hospital stay included all days during the index admission, interval readmissions and definitive surgical admission. Statistical analysis Data were summarized as mean+/-standard deviation for continuous variables and frequency with percentage for categorical variables. Continuous variables were compared using the independent-samples t test. Categorical outcomes were compared using the chi-square test or Fisher exact test. A two-sided p value <0.05 was considered statistically significant. Analysis was structured for IBM SPSS Statistics version 25 or an equivalent validated package.

One hundred patients were analysed, 50 in the early group and 50 in the delayed group. Age, sex, comorbidity profile, leukocyte count, gallbladder wall thickness and severity grade were comparable between groups (Table 1). Table 1: Baseline clinical characteristics Variable Early (n=50) Delayed (n=50) p value Age, years (mean+/-SD) 46.8+/-12.1 48.2+/-11.7 0.558 Male sex, n (%) 22 (44) 20 (40) 0.840 Diabetes mellitus, n (%) 8 (16) 9 (18) 1.000 Hypertension, n (%) 10 (20) 11 (22) 1.000 Symptom duration, hours 44.6+/-18.3 46.1+/-19.2 0.690 Leukocyte count, /mm3 13,480+/-3,120 13,210+/-2,980 0.659 GB wall thickness, mm 5.7+/-1.4 5.5+/-1.3 0.461 Tokyo Grade II, n (%) 18 (36) 16 (32) 0.832 The early group had more oedematous and friable gallbladders, and gangrenous change was observed in eight patients. The supplied operative photograph demonstrates a severely inflamed gallbladder with green-black necrotic discoloration consistent with gangrenous cholecystitis (Figure 1). Dense adhesions and bile spillage were numerically more frequent during early surgery, although these differences were not statistically significant. Subtotal cholecystectomy was required in two early and one delayed case Table 2: Intraoperative findings and bailout procedures Intraoperative finding Early (n=50) Delayed (n=50) p value Dense adhesions, n (%) 24 (48) 18 (36) 0.310 Gangrenous gallbladder, n (%) 8 (16) 3 (6) 0.200 Empyema, n (%) 7 (14) 4 (8) 0.523 Bile spillage, n (%) 9 (18) 5 (10) 0.388 Subtotal cholecystectomy, n (%) 2 (4) 1 (2) 1.000 Drain placement, n (%) 18 (36) 11 (22) 0.186 Mean operative time was modestly longer in the early group (71.6+/-18.9 vs 63.4+/-16.2 minutes; p=0.022). Conversion to open surgery was required in four early and three delayed cases. Reasons included inability to define safe anatomy, uncontrolled bleeding and dense frozen adhesions. No major bile duct injury occurred. Postoperative morbidity was comparable. Five patients in the early group and four in the delayed group experienced complications, predominantly superficial surgical-site infection or transient respiratory morbidity. One controlled bile leak occurred after subtotal cholecystectomy in the early group and resolved with drainage. There was no mortality. The principal difference was cumulative hospital use. Total hospital stay was 4.2+/-1.3 days in the early group and 8.9+/-2.1 days in the delayed group (p<0.001). Six delayed-group patients required unplanned readmission before definitive surgery because of recurrent biliary pain or recurrent cholecystitis (p=0.027). Table 3: Operative and postoperative outcomes Outcome Early (n=50) Delayed (n=50) p value Operative time, minutes 71.6+/-18.9 63.4+/-16.2 0.022 Conversion to open, n (%) 4 (8) 3 (6) 1.000 Postoperative complications, n (%) 5 (10) 4 (8) 1.000 Bile leak, n (%) 1 (2) 0 1.000 Postoperative stay, days 2.7+/-1.0 2.9+/-1.1 0.344 Total hospital stay, days 4.2+/-1.3 8.9+/-2.1 <0.001 Preoperative readmission, n (%) 0 6 (12) 0.027 Mortality, n (%) 0 0 -

The present comparative dataset suggests that early laparoscopic cholecystectomy achieves definitive treatment during the index admission and markedly reduces cumulative hospitalization. The trade-off was a modest increase in operative duration, likely reflecting oedema, tissue friability and active inflammatory adhesions. Importantly, this did not translate into higher conversion, overall morbidity or mortality. These findings are consistent with randomized evidence. Lo et al. reported that early surgery could be completed safely despite a technically demanding operative field [6]. Johansson et al. found comparable complication and conversion rates, with shorter total hospital stay in the early group [7]. The ACDC multicentre trial reinforced the superiority of immediate surgery over initial antibiotic treatment followed by delayed cholecystectomy, particularly regarding morbidity, hospital utilization and cost [8]. Meta-analyses have repeatedly shown reduced total stay without a significant increase in bile duct injury, bile leak or conversion [9-11]. A clinically important disadvantage of delayed surgery is the waiting-period risk. In this study, 12% of delayed-group patients required readmission before definitive treatment. Recurrence may present as biliary colic, repeat cholecystitis, pancreatitis or ductal stone complications. Even when the eventual elective operation is shorter, the combined burden of two admissions and recurrent symptoms can outweigh this benefit. Gangrenous cholecystitis deserves particular attention. Necrosis increases the likelihood of perforation, bile contamination and difficult grasping, and the normal tissue planes may be lost. The operative image in this report demonstrates these changes. In such cases, the objective is not completion of a textbook total cholecystectomy at any cost, but prevention of bile duct or vascular injury. Surgeons should pause when anatomy is uncertain, seek senior assistance, obtain intraoperative imaging where useful and proceed to a bailout procedure. Subtotal cholecystectomy is an accepted option when the hepatocystic triangle cannot be safely dissected [2-4,12]. The absence of major bile duct injury in both groups should be interpreted cautiously because such events are uncommon and this sample is underpowered for rare outcomes. A non-significant p value does not establish equivalence. Safety depends on patient selection, resuscitation, anaesthetic optimization, surgeon experience and willingness to abandon unsafe dissection. The study has several limitations. It is single-centre, the sample is modest, blinding is impossible and treatment allocation may be influenced by theatre availability or surgeon preference. Quality-of-life and cost data were not captured. Most importantly, the current numerical dataset is synthetic and must not be represented as observed patient data. The manuscript becomes submission-ready only after every result is reconciled with authentic records and the analysis is rerun.

Early laparoscopic cholecystectomy for Grade I and II acute calculous cholecystitis reduce total hospital stay and prevents waiting-period readmissions without an apparent increase in conversion or postoperative morbidity. The procedure may take slightly longer during active inflammation, but provides definitive treatment in one admission. Where appropriate surgical expertise, anaesthetic support and bailout capability are available, index-admission laparoscopic cholecystectomy should be preferred over routine delayed surgery. FUTURE SCOPE Future work should use prospectively registered multicentre cohorts with standardized Tokyo severity grading, objective operative-difficulty scores, Clavien-Dindo complication reporting, cost analysis and patient-reported outcomes. Video-based documentation of the critical view of safety and the threshold for subtotal cholecystectomy may further improve reproducibility and safety. Acknowledgement: The authors thank the patients and the Department of General Surgery, Vilasrao Deshmukh Government Medical College, Latur, for their cooperation.

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