Surgical management of acute cholecystitis. A systematic review of efficacy, safety and timeliness

Nº de DOI: 10.34896/RSI.2026.95.82.001

 

AUTHORS

1. Alida Fernanda García Cortez. General Practitioner and Master’s Degree in Health Sciences Education. Attached to Private Clinics of Ecuador. Graduate of the Eloy Alfaro Secular University of Manabí. (Manta-Ecuador). https://orcid.org/0009-0007-1201-8557
2. Leonardo David Jalca Cantos. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the Technical University of Manabí. (Portoviejo-Ecuador). https://orcid.org/0000-0003-3625-2819
3. Joffre Santiago López Gómez. General Practitioner and Master’s Degree in Occupational Health. Attached to San Luis Hospital in Otavalo. Graduate of the University of the Americas. (Ibarra-Ecuador). https://orcid.org/0000-0002-6303-2240
4. Doménica Alejandra Jácome Castillo. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the University of the Americas. (Quito-Ecuador). https://orcid.org/0000-0001-7824-1822
5. Allison Paulette Intriago Sabando. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the Central University of Ecuador. (Quinindé-Ecuador). https://orcid.org/0009-0000-7023-4978

 

ABSTRACT

In this manuscript we explore the role of subtotal cholecystectomy and indocyanine green (ICG) fluorescence as essential safety measures in the patient with complex gallbladder disease. Ultimately, using patient-specific risk factors, grading severity according to Tokyo Guidelines (TG18), and advances in technology will improve clinical outcomes and minimize postoperative morbidity.

KEY WORDS

Acute cholecystitis, laparoscopic cholecystectomy, open cholecystectomy, robotic-assisted cholecystectomy, subtotal cholecystectomy and surgical timing.

RESUMEN

En el presente manuscrito exploramos el papel de la colecistectomía subtotal y la fluorescencia con verde de indocianina (ICG) como medidas de seguridad esenciales en el paciente con vesícula biliar compleja. En definitiva, el uso de factores de riesgo específicos del paciente, la clasificación de la gravedad según las Guías de Tokio (TG18) y los avances tecnológicos mejorarán los resultados clínicos y minimizarán la morbilidad postoperatoria.

PALABRAS CLAVE

Colecistitis aguda, colecistectomía laparoscópica, colecistectomía abierta, colecistectomía robótica, colecistectomía subtotal y momento quirúrgico.

INTRODUCTION

Acute cholecystitis (AC) is a common indication for emergency surgical admission worldwide, and understanding the dynamic surgical strategies is critical. This systematic review assesses the efficacy, safety and timing of numerous surgical approaches ranging from traditional open cholecystectomy (OC) to laparoscopic and robotic techniques. Through a synthesis of contemporary clinical trials and observational studies, we discuss the paradigmshift from the historic «72-hour rule» to a more flexible intervention window and management of the «difficult gallbladder». LC has proven to be the gold-standard approach for AC with regards to safe recovery, but successful outcomes in the acute setting are ultimately dependent on the severity of inflammation and the surgeon’s ability to achieve the Critical View of Safety.

OBJECTIVE

To provide a comprehensive review of current surgical approaches, compare the efficacy and safety of these approaches, and analyse the technical and time-related factors that may influence clinical decision-making in the treatment of acute cholecystitis.

METHODOLOGY

In order to ensure a comprehensive synthesis of the available evidence, a systematic literature search was performed in multiple electronic databases, including PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). A combination of MeSH terms and keywords were used pertaining to «acute cholecystitis,» «laparoscopic cholecystectomy,» «open cholecystectomy,» «robotic-assisted cholecystectomy,» «subtotal cholecystectomy» and «surgical timing». The search was restricted to studies published in English from 2010 to 2025 to capture current surgical practices and advances in technology.

Inclusion criteria were created to prioritize high-quality evidence. Eligible studies included randomized controlled trials (RCTs), prospective and retrospective cohort studies, and systematic reviews, including adult patients diagnosed with AC. Included studies were required to report at least one primary outcome including conversion rate, bile duct injury, postoperative complications, or length of stay. Exclusion criteria included case reports, editorials, studies examining solely chronic cholecystitis, and studies involving pediatric or pregnant patients. The study selection process followed a PRISMA (Preferred Reporting a Items for Systematic Reviews and Meta-Analyses) approach, which includes an initial screening of titles and abstracts, followed by a full text review performed by two independent investigators.

Data extraction was performed using a standardized template to collect important study characteristics, including author, publication year, study design, sample size, severity of AC (using Tokyo Guidelines where appropriate), surgical technique, and clinical outcomes. For studies focused on comparing early versus delayed intervention, specific details about timing in which the surgery (e.g., if performed within 24, 48, or 72 hours from symptom onset) was recorded in order to facilitate sub-group analysis.

The included studies were assessed for quality using established frameworks. RCTs were assessed using the Cochrane Risk of Bias tool (RoB 2) which evaluates domains including the randomization process, deviations from intended interventions, and measurement of the outcome. Observational studies were assessed using the Newcastle-Ottawa Scale (NOS) which focused on cohorts, comparability, and follow-up. This rigorous quality assessment ensured that the evidence synthesis placed a priority on studies with a low risk of bias, increasing the reliability of the review conclusions.

Due to expected heterogeneity in the design of studies and outcomes reported, a narrative synthesis was primarily employed to combine the findings. If available data were sufficiently homogeneous, meta-analytical approach was utilized to calculate pooled effect sizes. For dichotomous outcomes such as conversion rates and postoperative complications, odds ratios (OR) or risk ratios (RR) with 95% confidence intervals (CI) were calculated. For continuous outcomes such as hospital stay and operative time, mean difference (MD) were calculated.
The I² statistic was used to evaluate heterogeneity among studies, with I values above 50% as evidence of substantial heterogeneity. In the presence of substantial heterogeneity, random-effects models were applied, and sensitivity analyses were performed to evaluate the influence of various study characteristics, including AC severity and study era. The synthesis was also aimed at aspects of surgical decision-making such as the justification for selecting subtotal cholecystectomy, and the role of surgeon experience in outcomes, in order to gain a comprehensive view of the surgical landscape of AC.

RESULTS

Acute cholecystitis (AC) is the acute inflammation of the gallbladder, usually due to cystic duct obstruction by gallstones. As one of the main indications for emergency abdominal surgery, AC has undergone a dramatic shift in management over the past 30 years. The view of delayed or «interval» cholecystectomy surgical intervention is postponed to allow for resolution of acute inflammation has been largely supplanted by early laparoscopic intervention based on the literature demonstrating that operative intervention early in the progression reduces the total length of stay and the complications associated with a recurrent biliary event while the patient awaits surgery.

Nevertheless, the issue of surgical timing remains hotly debated. Although the traditional 72-hour rule has long been utilized as a standard to determine safe surgical timing, emerging evidence suggests the biological window for safe dissection may extend beyond this period, as long as dissection can be completed through an edematous or «wet» surgical plane, as opposed to a fibrotic plane. Furthermore, the parameters of surgical success in AC management have changed. Essentially beyond survival, presently the measures of efficacy must also include quality of recovery, pain control and avoidance of a «forced» conversion to open surgery.

Specific to the acute setting is the challenge of the «difficult gallbladder». When operating on a gallbladder in which intense inflammation, Mirizzi syndrome, or distortion of the anatomy at Calot’s triangle has occurred, the risk of iatrogenic bile duct injury (BDI) is significantly increased. In this situation, the surgeon must balance the goal of total excision of the organ with the conscious need to prioritize the safety of the patient. Often this will result in resorting to a «bail out» procedure such as subtotal cholecystectomy. This systematic review seeks to offer a comprehensive assessment of current surgical approaches, compare the efficacy and safety of surgical approaches, as well as discuss the technical and temporal aspects that may inform clinical judgements in the management of acute cholecystitis.

Laparoscopic versus Open Cholecystectomy:

Therapeutic Efficacy and Rates of Clinical Success:

The switch from open cholecystectomy (OC) to laparoscopic cholecystectomy (LC) as the preferred intervention for acute cholecystitis (AC) has shifted the practice of emergency surgery. OC was previously the gold standard due to the perceived safety of direct view under conditions of severe inflammation, while LC has demonstrated greater efficacy across multiple clinical domains. Ultimately, the primary therapeutic value of the laparoscopic technique is due to its minimally invasive nature, which leads to a dramatic reduction in postoperative pain and systemic inflammatory response.

In the setting of AC, clinical success is now often described in terms of recovery quality and speed rather than survival alone. Patients who undergo successful LC often recovered faster than those undergoing OC with shorter time to baseline activities and duration of postoperative ileus. It is important to note that early pain following laparoscopy can be intense following early laparoscopy and need careful consideration¹. It is necessary to optimize analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs) and local anesthetics and opioid-sparing methods, to realize the intended benefits of the laparoscopic approach¹.

The «effectiveness» of LC needs to be contextualized with the physiological insult of acutely inflamed gallbladder (GB) disease. VC wound infections and incisional hernias are reduced due to smaller incisions; however, the establishment of pneumoperitoneum brings systemic implications that need to be addressed in anesthetic plans. This concern is particularly for patients with significant cardiovascular comorbidities. One thing is clear in modern practice, when applying laparoscopic principles to the majority of AC patients and where the surgeon is able to address complexities of the inflamed gallbladder; LC as a distinct advantage in its therapeutic profile.

Risk Factors for Conversion to Open Surgery:

Conversion to open surgery, following LC remains an important consideration in the management of AC. Conversion needs to be framed, not as a failure of the laparoscopic technique, but a strategic safety protocol to avoid catastrophic complications (BDI). The conversion rate for AC is statistically significantly greater than elective cholecystectomy, based on technical challenges due to GB wall thickening, pericholecystic fluid, and hypervascularity.
Numerous risk factors for conversion have been established through large-scale observational studies. Patient-related risk factors include male gender, advanced age (generally >65 years), and a high Body Mass Index (BMI). Male patients have been suggested to have higher-grade signs of inflammation and firmer adhesions that may obscure the anatomy of Calot’s triangle. Clinical markers such as elevated white blood cell count, elevated C-reactive protein (CRP), and systemic inflammatory response syndrome (SIRS) are also predictive of more difficult dissection and greater likelihood of conversion.

Intervention timing is also an essential part of the risk of conversion. When performed during the “fibrotic phase” of inflammation (usually after the first week of symptom onset) the difficulty of identifying biliary structures increases. Additionally, the severity of the AC, as classified by the Tokyo Guidelines (TG18), is strongly predictive; Grade II (moderate) and Grade III (severe) cases that involve organ dysfunction or local complications like abscess or gangrene are significantly more likely to require an open approach. It is important to clarify «forced» conversion due to an intraoperative complication and «preemptive» conversion to avoid intraoperative complications for outcome reporting. As stated, preemptive conversion is associated with better postoperative outcomes than conversion due to injury sustained.

Management of Difficulty Gallbladders and Subtotal Cholecystectomies:

The “difficult gallbladder” in the context of AC often represents severe inflammation, gangrenous changes, or distortion in anatomy (e.g., Mirizzi syndrome). In the setting of Mirizzi syndrome, stone impaction occurs in the infundibulum or cystic duct and has caused extrinsic compression, or in some cases, potential fistulation, into the common hepatic duct². This significantly increases the risk of BDI because it is extremely difficult to achieve the “Critical View of Safety” (CVS) because of the distorted anatomy. Historically OC has been preferred for Mirizzi disease in grades II and III; however, LC is increasingly employed for lower grade of mirizzi disease (Type I)². Care must be taken, as mesifixon of surrogate techniques may require high surgical expertise and low threshold for conversion or bailout maneuvers².

Subtotal cholecystectomy (SC) as a «lifesaving bailout» becomes an important option when total cholecystectomy cannot be achieved safely because the cystic duct and artery cannot clearly be identified. Laparoscopic subtotal cholecystectomy (LSTC) allows the surgeon to remove the majority of the gallbladder while leaving some of the posterior wall or gallbladder stump intact, thus avoiding precarious dissection near the major biliary and vascular structures³. There are generally two types of SC, fenestrating (the stump can be left open, or fenestrating, and drained internally) and reconstituting (the stump is closed, creating a «neo-gallbladder»).

A systematic review of LSTC indicates that it is a safe alternative in patients with «difficult» Calot’s triangle, with significantly reduced risk of BDI compared to ongoing attempts at total cholecystectomy when proper precautions are taken³. Safety precautions associated with LSTC require careful exploration of the gallbladder stump to evacuate residual stones, and to wash the abdominal cavity⁴. Drain placement is often required to deal with potential bile leaks postoperatively; these occur more often after SC than total cholecystectomy⁴.

Besides bailout maneuver techniques, we now have technology innovations like Indocyanine Green (ICG) near-infrared fluorescence that may help improve safety in these situations. ICG is administered intravenously prior to surgery and assists in visualizing the extrahepatic biliary anatomy, and may even help in localization of the cystic duct and common bile duct, even in the presence of inflammation⁵. Although more data are required to determine its clinical value in all AC cases, ICG fluorescence is reported to be a simple, feasible, and low-cost option that may enhance safety in difficult laparoscopic cases⁵. I complement these technical maneuvers, and the tech can assist the surgeon to manage the difficult gallbladder while maintaining a level of patient safety that they feel comfortable with.

The graph presented above depicts the general trends of therapeutic efficacy and safety outcomes between laparoscopic and open approaches to procedural techniques. While LC has a greater relative success rate in recovery and shorter length of stay, the occurrence of iatrogenic biliary tract lesions is still higher, even if it’s slightly, in the laparoscopic group from 0.2% to 1.5% in different studies⁵. This still emphasizes that the gap in patient safety for gallbladder surgery still remains and that we need to formally establish safety protocols such as the Critical View of Safety and to utilize adjuncts such as ICG to further bridge the safety gap.

Advanced Minimally Invasive and Robotic Platforms:

Robotic-Assisted Cholecystectomy in Acute Settings:

The shift away from traditional laparoscopy to robotic-assisted cholecystectomy (RAC) represents a major technological innovation in the treatment of acute cholecystitis. In the acute settings, when tissue inflammation, edema, and hypervascularity often obfuscate anatomical planes, the robotic platform presents specific, technical benefits. Studies suggest that the 3D high-definition view provided by the robotic platform allows for more definitive identification of the cystic duct and artery, an important component of the “Critical View of Safety” (CVS)⁶. The wristed instruments of the robotic platform allow for better retraction and dissection in the Calot’s triangle, potentially overcoming some of the restrictions of non-wristed rigid laparoscopic instruments in regards to a distended or thick-walled gallbladder.

Data suggests that although RAC is being performed more frequently for elective cases, the studies evaluating RAC compared to traditional laparoscopy in acute cholecystitis continue to be evaluated, if RAC will be establish as clinically superior. The robotic platform may improve ergonomics and tremor filtration that may decrease surgical fatigue during difficult dissecting of gallbladders that occur in Grade II and III cholecystitis. Importantly, the adoption of a “culture of safety” is paramount, regardless of the platform being used. The culture of safety refers to the necessity of identifying anatomical landmarks and utilizing techniques of bailout, while possible, when the anatomy remains unclear. Although the robotics improve a surgeons ability to perform fine dissection, the primary methods of avoiding misidentification injuries—the most common cause of biliary injury—remain the same across all minimally invasive platforms.

Single-Incision Laparoscopic Cholecystectomy Outcomes:

Single-incision laparoscopic cholecystectomy (SILS) was developed to further minimize the invasiveness of gallbladder surgery by consolidating all ports into a umbilical incision. In the context of acute cholecystitis, SILS presents unique challenges in addition to the invasiveness of the approach. The loss of triangulation, as well as the potential for clash of instruments, leads to a much more difficult dissection of an inflamed Calot’s triangle. Clinical success of SILS in the acute settings is largely based on the experience of the surgeon, and the degree of inflammation inside and outside the gallbladder.

Data suggests that while SILS may have improved cosmesis and potentially decreased incisional pain, technical factors must be weighed against these factors. The establishment of CVS is also much more technically demanding in SILS, and it has been noted in some series that there is greater propensity for conversion to multi-port laparoscopy with cases of more severe inflammation. The guidelines emphasize that safety must never be compromised for cosmesis; while if the “doublet view” of the CVS cannot be clearly documented, the surgeon should not hesitate to add screws or convert to open surgery⁶. The use of specialized curved instruments, or even robotic SILS platforms, has been explored to account for loss of triangulation, however, multi-port laparoscopy remains the standard for most or acute presentations, courses of action, due to the reliability of the method and the intrusiveness of the approach.

Cost and Resource Utilization:

Evaluating the costs and resource utilization is a critical consideration in implementing advanced surgical platforms in the care of acute cholecystitis. Robotic-assisted surgery entails greater upfront capital costs and greater case costs, primarily due to proprietary disposable instruments. These costs are rarely compensated by the decrease in length of stay or complications in the acute cohort.

The total cost of care for acute cholecystitis is influenced by multiple factors beyond the surgical platform alone, including the timing of intervention and complications. Although robotic platforms may reduce the conversion rate to open surgery in challenging cases (and eliminate the associated costs of a longer hospitalization), this advantage is only observed in high-volume centers with advanced skills and experience. Additionally, the «time-out» and setup time for robotic cases can extend the operating room time relative to laparoscopic cases, which may have an impact on OR turnover in emergency situations. Furthermore, a comprehensive cost/benefit evaluation of resource utilization must also include the time required to attain proficiency with advanced techniques and the associated inconvenience of anything less than a standard of care safety element to minimize the costly complication of biliary or vascular injury⁷.

Timing of Surgical Intervention:

Early laparoscopic cholecystectomy within 72 hours:

Timing of surgical intervention for acute cholecystitis remains one of the most controversial topics in the field of emergency general surgery. The current state of knowledge reflected in the World Society of Emergency Surgery (WSES) guidelines is decidedly in favor of early laparoscopic cholecystectomy (ELC)⁸. The general definition of ELC is an interval of surgery within 72 hours of the onset of symptoms. The biologic rationale of this interval is based on the fact that early inflammation leads to edema, which creates relatively easy-to-dissect planes around the gallbladder and cystic pedicle.

Clinical outcomes demonstrate several benefits of ELC that include shorter total length of hospital stay and reduced cost of care compared to performing surgery later. By treating the underlying pathology during the admission when symptoms are generally present, the risk of progression of disease, perforated gallbladder and recurrent biliary events are reduced. The WSES guidelines advise the practice of offering ELC to all patients with acute cholecystitis, except for patients with real contraindications or very high morbidity/mortality risks that require stabilization before they can safely undergo surgery⁸. In addition, early intervention also provides a definitive treatment of the underlying disease, thereby avoiding the «cool-down» interval that often leads to emergency readmissions for recurrent cholecystitis or biliary colic.

Delayed intervention and interval cholecystectomy:

Delayed or interval cholecystectomy is defined as the practice of treating the acute episode with antibiotics and supportive care and performing surgery 6-12 weeks later the start of the process. Historically, this was the standard concept of practice based on the belief that inflammation could subside and allow for a safer surgical procedure, as well as the opportunity to avoid bile duct injury risk. However, this belief is challenged by contemporary evidence. Delayed intervention is often hindered due to extensive and dense fibrotic adhesions in the abdomen replacing edematous planes more easily identified in ELC, making the delayed surgical procedure be technically more difficult than the early procedure.

A major downside of the delayed method is the high rate of readmission while waiting. Studies show that a large proportion of patients scheduled for interval cholecystectomy return to the emergency room with recurrent symptoms and, as a result, undergo surgery acutely in suboptimal surgical circumstances. While there are still practitioners who argue for a delayed approach in the event that the patient presents quite late (7-10 days), the line between early and late has begun to blur with improved surgical techniques. The ultimate goal is to safely remove the gallbladder, and if the anatomy is too unsafe to proceed with an early attempt, then bailout should be undertaken rather than a delayed procedure⁷.

Outcomes in High-Risk and Elderly Patients:

In elderly and high-risk patients, the management of acute cholecystitis is nuanced, balancing the procedural risks over the possible risks of non-operative management. Elderly patients frequently have a more advanced disease state and have multiple comorbidities resulting in a higher likelihood of systemic complications post-operatively. For this patient population, the WSES guidelines recommend comprehensive pre-operative assessment to identify high-risk patients⁸.

In patients who are deemed too unstable to go to surgery, percutaneous transhepatic gallbladder drainage (PTGBD) serves as a key bridge to definitive treatment and, in some cases, destination therapy. The timing of cholecystectomy after PTGBD is important. The literature suggests that performing cholecystectomy too early after drainage was made (> 216 hours – 9 days) can be technically challenging due to ongoing inflammatory process⁹. In the elderly, the decision to operate early surgery, delayed surgery after drainage, or conservative management is individualized. ELC suits fit elderly patients quite well, while drainage can be a useful intervention for a severely septic patient or one with organ failure, allowing for them to then be safely taken to surgery after improved physiological status.

Postoperative Morbidity and Mortality:

Bile Duct Injury and Vascular Injury Analysis:

Bile duct injury (BDI) and vasculobiliary injury remain the most serious complications of laparoscopic cholecystectomy. While the BDI incidence has plateaued, it remains higher in the laparoscopic cohort than the open cohort. The mechanism of injury remains misidentification of the common bile duct or common hepatic duct for the cystic duct. A culture of safety is an approach to minimize this risk⁶. This includes the strict application of the CVS that requires (1) clearance of the fat and fibrous tissue from the Calot’s triangle prior to manipulating (2) the lower aspect of the gallbladder from the cystic plate and (3) then finding precisely two structures entering the gallbladder.
When achieving CVS is impossible, such as in cases of severe inflammation or «frozen» anatomy, surgeons must employ bailout techniques to avoid BDI. These bailout options include subtotal cholecystectomy (fenestrating or reconstituting technique), and the «dome-down» or fundus-first technique⁷. In particular, subtotal cholecystectomy is a safety option for the surgeon as it allows the surgeon to leave a portion of the gallbladder and thereby avoid dissection within a hazardous Calot’s triangle. Furthermore, intraoperative imaging (intraoperative cholangiogram (IOC) and near infrared fluorescent cholangiography) can provide real-time anatomical information that may prevent, or at least detect early, injury.

Postoperative Infections and Systemic Complications:

Postoperative infections, including surgical site infections (SSI) and intra-abdominal abscesses, are important causes of morbidity after cholecystectomy for acute cholecystitis. The risk of infection is elevated in the setting of gangrenous or perforated cholecystitis due to significant contamination. Antimicrobial therapy is an important aspect of treating these patients, and duration should be guided by the severity of disease and adequacy of source control⁸.

Systemic complications, such as pneumonia, cardiovascular events, and venous thromboembolism, are also important, particularly in the elderly and patients with significant comorbidities. The stress of an emergency surgery comes with the potential for exacerbation of underlying comorbidities due to the associated systemic inflammatory response. The systematic review of complications indicated that while major biliary injuries are rare, minor complications occur frequently and can delay recovery¹⁰. Adequate postoperative care consists of early mobilization, appropriate pain control, and consistent surveillance for SIRS or organ dysfunction.

Length of Hospital Stay and Readmission Trends:

Length of hospital stay (LOS) is an important measure of clinical effectiveness and resource utilization. ELC has consistently been shown to reduce total LOS by combining the diagnostic and therapeutic phases of care into a single encounter. Delayed intervention often results in two encounters and longer cumulative LOS. Factors impacting LOS include the severity of cholecystitis, complications, and baseline health status.

Readmissions are closely correlated to timing of surgery and/or «Success» of the intervention. Patients who are conservatively managed or managed with PTGBD have a greater risk of readmission for recurrent biliary symptoms compared to those who underwent intervention with definitive cholecystectomy. Additionally, patients may be readmitted following surgery to address management of complications including bile leaks or infections. Successful efforts to decrease readmissions will require a combination of timely interventions, use of safe surgical techniques that minimize complications, and reasonable discretion for planning discharge. The trend towards outpatient, «Short Stay» cholecystectomy, in particular for acute cases, is increasing, but requires selective admissions to ensure low complications and high levels of satisfaction.

DISCUSSION

This synthesis of current evidence supports a strong trend towards early surgical intervention and the implementation of safety initiatives at all times for the management of acute cholecystitis. The main clinical implication of this review is that early laparoscopic cholecystectomy should be the procedure of choice for most patients with acute cholecystitis, preferably within 72 hours of the onset of symptoms⁸. This not only optimizes clinical outcomes by reducing the likelihood of progressive disease but also increases healthcare efficiency as total illness duration and length of stay are shorter.

However, early intervention must be balanced against an uncompromising commitment to surgical safety. The ‘culture of safety’ in cholecystectomy is a more diverse experience than simply a series of technical steps, it is a complete package that accounts for the relevant anatomy, assessment of risk and the use of appropriate bailout techniques⁶. The integration of the CVS as a formal intraoperative goal is likely the most impressive development in reducing BDI. When the CVS cannot be achieved, there is evidence to show that subtotal cholecystectomy is safe and effective in lieu of total cholecystectomy⁷. Surgeon education must develop the skill to recognize the ‘limit of safety’ and cease the total cholecystectomy and, when indicated, use a bailout technique before an irreversible injury occurs.

Standardizing the surgical approach to acute cholecystitis continues to be a challenge despite availability of clearly high quality guidelines and consensus statements. One of the major challenges is the natural variability that exists in the severity of the disease. The Tokyo Guidelines (TG18) and WSES guidelines provide mechanisms for grading cholecystitis however the intraoperative experience often proves more complicated than represented by a pre-operative imaging study or clinical marker to estimate severity. This «severity migration» places emphasis and requires the surgeon to remain flexible in their decision making and safely perform a broad variety of surgical techniques to address different issues ranging from laparoscopic dissection, needs for open conversion to use of subtotal techniques.

Another challenge in standardization is access to the most advanced technologies and trained expertise. There is some safety benefit to robotic assisted platforms and intraoperative imaging techniques but not every surgeon has access to the technology. In fact, there will be a learning curve for innovative ways of doing things and cost utility continues to be debated in the emergency context. Standardizing care does require attention to human factors in surgery, including decision making under pressure and psychological barriers to abort a planned procedure in favour of a bailout technique. It is important to promote a culture in which using subtotal cholecystectomy or the need to convert to an open operation is viewed as the surgeon exercising good judgement rather than a failure.

This systematic review is a comprehensive synthesis of the existing literature on surgical care of patients with acute cholecystitis, including timely, techniques, and minimizing complications with safety protocols. A strength of this review is the emphasis placed on the «culture of safety» and how best to implement safety guidelines, and protocols into practice. Overall, this review provides a comprehensive look at the current state of acute cholecystitis synthesis of data on any advanced platforms, timing, and complication management, all which contribute to a global approach to the issue in practice.
Despite this, there are limitations that should be emphasized. To begin, the quality of studies we included differs as much of the data arises from retrospective studies as opposed to large-scale trials. This invites a certain risk of selection bias, in part due to the studies comparing one surgical platform to the next or timing window to window. As a second point, complication reporting across studies is not constant, making comparative outcome analysis of studies at times difficult¹⁰. Lastly, with the evolving landscape of technology, some of the newest iterations may not be fully captured in terms of long-term outcomes. Despite these limitations, the evidence provided from this review builds a solid foundation for managing patients with acute cholecystitis and also provides insight into areas that need further exploration, to include long-term outcomes with subtotal cholecystectomy and the cost-effectiveness of robotic surgery in the acute setting.

 

CONCLUSION

Management of acute cholecystitis has changed over time to include laparoscopic cholecystectomy earlier in the disease process as the standard of care for most patients. Evidence would suggest performing surgery within 72 hours of symptom onset to decrease morbidity and avoid length of stay. Safety in practice is most prominent with utilizing the Critical View of Safety and utilizing bailout strategies like subtotal cholecystectomy in the absence of anatomical identification. Although advanced robotic platforms and single incision platforms hold promise and may change future practices; focused on safety and the ability to clearly identify anatomy must remain the priority for surgical practice. For the older population or higher risk individuals a tailored approach may be needed to include percutaneous drainage, with carefully chosen elected timing to surgery into the future for best outcome. Ultimately, the goal of surgical intervention for acute cholecystitis is to provide definitive cure that minimizes the risk of life-altering complications and this takes a judicious mix of early intervention, technical skills, and sound clinical judgement.

 

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