Acute cholecystitis is one of the most frequently encountered surgical emergencies worldwide and represents a substantial burden on healthcare systems [1,2]. It results from cystic duct obstruction, most commonly by gallstones, leading to gallbladder inflammation that may progress to ischemia, gangrene, or perforation if left untreated [2]. The clinical presentation typically includes right upper quadrant pain, fever, leukocytosis, and characteristic findings on ultrasonography. Initial management involves analgesia, intravenous fluid resuscitation, and antibiotic therapy, followed by definitive surgical treatment [3,4]. Laparoscopic cholecystectomy has become the standard of care for patients who are suitable surgical candidates, offering reduced postoperative pain, shorter hospital stay, earlier return to normal activity, and superior cosmetic outcomes compared with open cholecystectomy [5,6]. The optimal timing of laparoscopic cholecystectomy in acute cholecystitis has been debated for decades [7,8]. Traditionally, surgeons favored an initial conservative approach with antibiotics, followed by delayed elective cholecystectomy after a cooling-off period of six to eight weeks, because operating on an acutely inflamed gallbladder was considered technically challenging and associated with higher rates of bile duct injury and conversion to open surgery [9]. However, this approach carries the inherent risk of recurrent symptoms, readmission, and progression to complicated disease during the waiting period. The landmark ACDC trial, published in 2013, demonstrated that early laparoscopic cholecystectomy was superior to delayed surgery, with significantly lower morbidity (11.8% versus 34.4%) and shorter hospital stay (5.4 versus 10.0 days) [10]. Since then, multiple randomized controlled trials and meta-analyses have consistently shown that early surgery is safe and effective, without increasing major complications or bile duct injury [11,12]. Current international guidelines, including the Tokyo Guidelines 2018 (TG18), recommend early laparoscopic cholecystectomy as the preferred treatment for acute cholecystitis in suitable patients, ideally within 72 hours of symptom onset, while accepting that surgery remains appropriate beyond this window during the index admission [13]. Despite this strong evidence, implementation of early surgery remains variable in clinical practice, with many surgeons still opting for an initial conservative approach because of concerns regarding technical difficulty, surgeon experience, and resource availability [14]. In our regional context, there is a paucity of prospective data on the outcomes of early laparoscopic cholecystectomy using contemporary surgical techniques and standardized perioperative care protocols. The present study was therefore designed to evaluate the morbidity and mortality associated with early laparoscopic cholecystectomy in patients with acute cholecystitis at our institution. OBJECTIVES Primary objective: To evaluate the morbidity and mortality associated with early laparoscopic cholecystectomy (performed within 72 hours of hospital admission) in patients diagnosed with acute cholecystitis. Secondary objectives: (i) To determine the rate of conversion to open surgery and its causes; (ii) to assess the length of postoperative hospital stay and its relationship with the timing of surgery from symptom onset; and (iii) to identify preoperative clinical, laboratory, and intraoperative factors associated with postoperative morbidity, including the TG18 severity grade, preoperative C-reactive protein level, and comorbidities.

Study Design, Setting, and Ethics This prospective observational study was conducted in the Department of General Surgery, Neelima Hospital (Neelima Institute of Medical Sciences), Hyderabad, over a period of four months, from 5 April 2026 to 5 August 2026. A total of 48 consecutive patients who met the inclusion criteria and provided written informed consent were enrolled. The study was approved by the Institutional Ethics Committee of Neelima Hospital before commencement (approval no. IEC/2026/04/12). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments. Inclusion Criteria • Patients aged 18–75 years of either sex. • Clinical and sonographic diagnosis of acute cholecystitis (right upper quadrant pain, fever >38°C, leukocytosis >10,000/mm³, and ultrasonographic findings of gallbladder wall thickening >4 mm, pericholecystic fluid, or a sonographic Murphy’s sign). • Surgery performed within 72 hours of hospital admission. • American Society of Anesthesiologists (ASA) physical status I–III. • Written informed consent for participation in the study. Exclusion Criteria • Acute cholecystitis managed conservatively or by delayed cholecystectomy. • Suspected or confirmed gallbladder malignancy. • Common bile duct stones requiring preoperative endoscopic retrograde cholangiopancreatography (ERCP). • Severe sepsis or septic shock requiring intensive care admission. 1. Contraindications to pneumoperitoneum or general anesthesia. 2. Pregnancy. 3. ASA physical status IV or V. 4. Refusal of surgery or of consent to participate. Data Collection A structured proforma was used to collect data prospectively. Preoperative data included demographic characteristics (age, sex, body mass index), clinical presentation (duration of symptoms, fever, right upper quadrant tenderness), comorbidities (diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease), and laboratory parameters (total leukocyte count, C-reactive protein, serum bilirubin, serum amylase, liver function tests). Ultrasonographic findings were recorded, including gallbladder wall thickness, pericholecystic fluid, gallbladder distension, and gallstones. The severity of acute cholecystitis was graded according to TG18 as Grade I (mild), Grade II (moderate), or Grade III (severe) [4]. Intraoperative data included operative time, operative findings (degree of inflammation, adhesions, gallbladder perforation, gangrene), conversion to open surgery and its reasons, and estimated blood loss. Postoperative data included complications (surgical site infection, bile leak, intra-abdominal collection, postoperative ileus, respiratory complications, urinary retention, deep vein thrombosis), length of postoperative hospital stay, readmission within 30 days, and mortality. Complications were classified according to the Clavien-Dindo system [15]. All patients were followed up for a minimum of 30 days postoperatively through outpatient visits or telephone interviews. For subgroup analysis, patients were divided according to the interval from symptom onset to surgery (≤72 hours versus >72 hours). Statistical Analysis Data were entered into Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation or median with interquartile range, depending on the distribution of the data. Categorical variables were expressed as frequencies and percentages. Continuous variables were compared between groups using the independent samples t-test, and categorical variables using the chi-square test or, where any expected cell count was below five, Fisher’s exact test. Univariate analysis was performed to identify factors associated with postoperative morbidity, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Because of the small number of morbidity events (n=7), multivariable analysis was not performed. A two-sided p-value <0.05 was considered statistically significant.

The study population comprised 48 patients with a mean age of 46.3 ± 12.7 years and a female predominance (66.7%) (Table 1). The majority of patients (58.3%) had TG18 Grade I (mild) cholecystitis, while 33.3% had Grade II (moderate) and 8.3% had Grade III (severe) disease. The mean duration of symptoms at presentation was 38.6 ± 15.2 hours, and the mean preoperative C-reactive protein level was 58.4 ± 32.1 mg/L, reflecting a marked inflammatory response. The mean gallbladder wall thickness on ultrasonography was 6.2 ± 1.8 mm. Table 1: Demographic and Clinical Characteristics of the Study Population (n=48) Characteristic Value Age (years), mean ± SD 46.3 ± 12.7 Male, n (%) 16 (33.3) Female, n (%) 32 (66.7) BMI (kg/m²), mean ± SD 26.8 ± 4.2 Duration of symptoms (hours), mean ± SD 38.6 ± 15.2 Diabetes mellitus, n (%) 10 (20.8) Hypertension, n (%) 12 (25.0) Ischemic heart disease, n (%) 3 (6.3) Preoperative WBC count (cells/mm³), mean ± SD 14,250 ± 4,680 Preoperative CRP (mg/L), mean ± SD 58.4 ± 32.1 Gallbladder wall thickness (mm), mean ± SD 6.2 ± 1.8 TG18 Grade I (mild), n (%) 28 (58.3) TG18 Grade II (moderate), n (%) 16 (33.3) TG18 Grade III (severe), n (%) 4 (8.3) SD, standard deviation; BMI, body mass index; WBC, white blood cell; CRP, C-reactive protein; TG18, Tokyo Guidelines 2018. The mean operative time was 92.4 ± 28.6 minutes, and the mean estimated blood loss was 68.5 ± 42.3 mL (Table 2). Conversion to open surgery was required in 3 patients (6.3%), most commonly because of dense adhesions or unclear anatomy (n=2). Gallbladder perforation occurred intraoperatively in 6 patients (12.5%), and a gangrenous gallbladder was encountered in 4 patients (8.3%). Intraoperative bile spillage occurred in 8 patients (16.7%), and an intra-abdominal drain was placed in 22 patients (45.8%). Table 2: Intraoperative Findings and Operative Details (n=48) Parameter Value Operative time (minutes), mean ± SD 92.4 ± 28.6 Estimated blood loss (mL), mean ± SD 68.5 ± 42.3 Conversion to open surgery, n (%) 3 (6.3) Dense adhesions/unclear anatomy 2 (4.2) Bleeding 1 (2.1) Gallbladder perforation, n (%) 6 (12.5) Gangrenous gallbladder, n (%) 4 (8.3) Intraoperative bile spillage, n (%) 8 (16.7) Placement of intra-abdominal drain, n (%) 22 (45.8) SD, standard deviation. The overall morbidity rate was 14.6% (7 of 48 patients) (Table 3). Surgical site infection was the most common complication, occurring in 2 patients (4.2%). Bile leak, intra-abdominal collection, postoperative ileus, urinary retention, and atelectasis each occurred in 1 patient (2.1%). All complications were Clavien-Dindo Grade I–II and were managed conservatively; no patient required reoperation, radiological or endoscopic intervention, or intensive care admission. No mortality occurred during the hospital stay or within the 30-day follow-up period. Table 3: Postoperative Complications by Clavien-Dindo Grade (n=48) Complication Clavien-Dindo grade n (%) Surgical site infection I–II 2 (4.2) Bile leak II 1 (2.1) Intra-abdominal collection II 1 (2.1) Postoperative ileus I 1 (2.1) Urinary retention I 1 (2.1) Atelectasis I 1 (2.1) Total morbidity 7 (14.6) Mortality 0 (0) Each complication occurred in a different patient. Patients operated on within 72 hours of symptom onset (n=34) had a significantly shorter operative time (86.2 ± 24.8 vs. 107.5 ± 31.2 minutes, p=0.016) and a shorter postoperative hospital stay (3.6 ± 1.4 vs. 5.8 ± 2.1 days, p<0.001) than those operated on after 72 hours (n=14) (Table 4). Conversion (2.9% vs. 14.3%) and postoperative morbidity (8.8% vs. 28.6%) were also lower in the early subgroup, but these differences did not reach statistical significance (p=0.200 and p=0.171, respectively). Table 4: Comparison of Outcomes by Interval from Symptom Onset to Surgery Parameter ≤72 hours (n=34) >72 hours (n=14) p-value Operative time (minutes), mean ± SD 86.2 ± 24.8 107.5 ± 31.2 0.016a Conversion to open surgery, n (%) 1 (2.9) 2 (14.3) 0.200b Postoperative morbidity, n (%) 3 (8.8) 4 (28.6) 0.171b Postoperative hospital stay (days), mean ± SD 3.6 ± 1.4 5.8 ± 2.1 <0.001a SD, standard deviation. aIndependent samples t-test; bFisher’s exact test. On univariate analysis, age >60 years (OR 7.78, p=0.027), TG18 Grade II–III cholecystitis (OR 11.57, p=0.016), preoperative CRP >50 mg/L (OR 14.50, p=0.008), and gallbladder wall thickness >6 mm (OR 7.75, p=0.024) were significantly associated with postoperative morbidity (Table 5). Conversion to open surgery (OR 16.00, p=0.052) and diabetes mellitus (OR 3.64, p=0.147) showed a trend toward increased morbidity that did not reach statistical significance. The confidence intervals were wide, reflecting the small number of events. Table 5: Factors Associated with Postoperative Morbidity (Univariate Analysis) Variable Morbidity (n=7) No morbidity (n=41) OR (95% CI) p-value Age >60 years 4 (57.1) 6 (14.6) 7.78 (1.38–43.85) 0.027 Diabetes mellitus 3 (42.9) 7 (17.1) 3.64 (0.66–20.02) 0.147 TG18 Grade II–III 6 (85.7) 14 (34.1) 11.57 (1.27–105.83) 0.016 CRP >50 mg/L 6 (85.7) 12 (29.3) 14.50 (1.57–133.69) 0.008 Gallbladder wall >6 mm 5 (71.4) 10 (24.4) 7.75 (1.30–46.33) 0.024 Conversion to open surgery 2 (28.6) 1 (2.4) 16.00 (1.22–209.94) 0.052 Values are n (%). OR, odds ratio; CI, confidence interval (Woolf method); TG18, Tokyo Guidelines 2018; CRP, C-reactive protein. P-values from Fisher’s exact test.

The present study demonstrates that early laparoscopic cholecystectomy for acute cholecystitis is associated with low morbidity (14.6%), no mortality, and an acceptable conversion rate (6.3%) in our institutional setting. These findings align with the growing body of evidence from randomized controlled trials and meta-analyses supporting the safety and feasibility of early surgery [1,7,11]. A recent meta-analysis of 21 randomized controlled trials comprising 1,731 patients showed that early laparoscopic cholecystectomy significantly reduced total hospital stay without increasing conversion to open surgery, bile duct injury, operative time, or overall postoperative complications [7]. Similarly, a Cochrane review of randomized trials (488 participants) found no significant difference between early and delayed surgery in bile duct injury or conversion to open surgery, while early surgery shortened total hospital stay by approximately four days [8]. Our results are consistent with these findings and suggest that concerns regarding technical difficulty and higher complication rates with early surgery may be overstated in contemporary practice. The overall morbidity rate of 14.6% in our study is comparable to the 15.1% reported in a multicenter cohort of 1,868 patients undergoing early laparoscopic cholecystectomy for acute cholecystitis and to the 11.8% reported in the early surgery arm of the ACDC trial [10,16]. The most common complication in our series was surgical site infection (4.2%), followed by bile leak and intra-abdominal collection (2.1% each). Importantly, all complications were Clavien-Dindo Grade I–II and were managed conservatively, with no patient requiring reoperation or intensive care admission. By contrast, with delayed cholecystectomy the waiting period exposes patients to recurrent acute cholecystitis, pancreatitis, and other gallstone-related complications that can substantially increase overall morbidity [17]. A randomized controlled trial by Meena et al. reported postoperative complications in 13.3% of patients undergoing early cholecystectomy compared with 26.7% in the delayed group, with a significantly shorter hospital stay in the early group (4.2 ± 1.3 vs. 7.5 ± 2.1 days, p<0.05) [9]. Our mean postoperative hospital stay of 4.2 ± 1.8 days is consistent with these findings. The conversion rate of 6.3% in our study lies within the wide range reported in the literature, from about 3% in mixed elective and emergency series to approximately 20% in randomized trials of early surgery for acute cholecystitis, depending on patient selection and surgeon experience [8,18]. A recent audit of 355 laparoscopic cholecystectomies reported an overall conversion rate of 3.4%, rising to 9.3% in emergency procedures, with acute cholecystitis being independently associated with conversion [18]. In our series, conversion was numerically more frequent in patients operated on more than 72 hours after symptom onset (14.3% vs. 2.9%), although this difference was not statistically significant (p=0.200), likely owing to the small number of events. Operative time and postoperative stay, however, were significantly shorter when surgery was performed within 72 hours of symptom onset. This pattern is consistent with the pathophysiological understanding that progressive inflammation leads to increasing tissue edema, adhesions, and difficulty in delineating anatomical structures, thereby increasing the technical complexity of the procedure [19]. The meta-analysis by Khan et al., which examined timing defined by both symptom onset and hospital admission, likewise supports the safety of early surgery during the index admission [7]. Univariate analysis in our study identified age >60 years, TG18 Grade II–III cholecystitis, preoperative CRP >50 mg/L, and gallbladder wall thickness >6 mm as factors significantly associated with postoperative morbidity. These findings are broadly consistent with the Chole-Risk score, derived from a multicenter study of 1,868 patients, which identified previous percutaneous cholecystostomy, previous abdominal surgery, diabetes, Charlson Comorbidity Index >6, raised total bilirubin, dilated bile duct, perforated gallbladder, and severity grade as independent predictors of postoperative complications [16]. The association between elevated preoperative CRP and morbidity in our study (OR 14.50, p=0.008) is supported by a recent study in which patients with acute cholecystitis had significantly higher preoperative CRP levels than patients with uncomplicated gallstone disease (25.4 vs. 7.1 mg/L), together with longer hospital stays (7.4 vs. 2.2 days) and more complications [20]. These findings suggest that preoperative inflammatory markers may be useful for risk stratification and patient counseling, although the wide confidence intervals in our study warrant cautious interpretation. The strengths of this study include its prospective design, standardized data collection, use of TG18 for severity grading, systematic 30-day follow-up of all patients, and use of the Clavien-Dindo classification, which allows standardized reporting and comparison with other studies. LIMITATIONS OF THE STUDY This study has several limitations. First, the sample size of 48 patients, while sufficient for a preliminary assessment, limits the statistical power to detect small but clinically meaningful differences; the small number of events also produced wide confidence intervals. Larger multicenter studies are needed to validate our findings. Second, the study was conducted at a single institution, which may limit the generalizability of the results to settings with different patient populations, surgical expertise, and resources. Third, the absence of a comparator group undergoing delayed laparoscopic cholecystectomy prevents direct comparison of early and delayed strategies within our institution. Fourth, the 30-day follow-up may not capture late complications such as bile duct strictures or incisional hernias, which may manifest months or years after surgery. Fifth, factors associated with morbidity were identified by univariate analysis only; multivariable analysis in a larger sample would provide more robust risk stratification. Finally, procedures were performed by multiple surgeons with varying experience, which may have introduced heterogeneity in intraoperative decision-making and outcomes.

This prospective observational study demonstrates that early laparoscopic cholecystectomy for acute cholecystitis is a safe and feasible procedure, associated with low morbidity (14.6%), no mortality, and an acceptable conversion rate (6.3%). The most common complications were surgical site infection, bile leak, and intra-abdominal collection, all of minor to moderate severity and managed conservatively. Surgery within 72 hours of symptom onset was associated with significantly shorter operative time and postoperative hospital stay, with numerically lower conversion and morbidity rates. These findings support the recommendations of the Tokyo Guidelines 2018 and the growing body of evidence favoring early surgery over initial conservative management followed by delayed cholecystectomy. Older age, higher TG18 grade, elevated CRP, and increased gallbladder wall thickness were associated with postoperative morbidity and may aid in risk stratification and patient counseling. We recommend that early laparoscopic cholecystectomy be considered the preferred treatment for patients with acute cholecystitis who are suitable surgical candidates, performed during the index admission and as soon as possible after symptom onset. Larger multicenter studies with longer follow-up are warranted to validate these findings, evaluate long-term outcomes including late biliary complications and quality of life, and develop predictive models that integrate clinical, laboratory, and imaging parameters to guide surgical decision-making. ACKNOWLEDGEMENT The authors thank the Department of General Surgery, Neelima Hospital, for its support throughout the study, and the nursing staff, operation theatre personnel, and medical records department for their assistance in data collection and patient follow-up. We are grateful to the Institutional Ethics Committee for its timely review of the study protocol, and to the patients and their families for their participation and trust. Conflict of Interest: The authors declare no conflict of interest. Source of Funding: None.

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