Laparoscopic Cholecystectomy for Acute Cholecystitis: Prospective Trial
Authors: Eldar Samuel , Sabo Edmond , Nash Ernest , Abrahamson Jack , Matter Ibrahim 
Published: February 2006

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy
(LC) following the onset of acute cholecystitis. It also evaluates
preoperative and operative factors associated with conversion from
laparoscopic cholecystectomy to open cholecystectomy in the presence of
acute cholecystitis. Having been established as the procedure of choice
for elective cholelithiasis, LC is now also used for management of
acute cholecystitis. Under these circumstances the procedure may be
difficult and challenging. Certain favorable and unfavorable conditions
may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the
optimal circumstances for LC or when the procedure is best avoided. We
performed LC on an emergency basis as soon as the diagnosis was made on
all patients presenting with acute cholecystitis from January 1994 to
December 1995. All preoperative, operative, and postoperative data were
collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic
intraoperative cholangiography to have choledocholithiasis were
converted for common bile duct exploration and were excluded from the
study. Altogether 93 patients (72%) underwent successful LC and 37
(28%) needed conversion to open cholecystectomy. The conversion rate
of acute gangrenous cholecystitis (49%) was significantly higher than
that for uncomplicated acute cholecystitis (4.5%) (p< 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p= 0.004). The difference in conversion
between the group with acute necrotizing (gangrenous) cholecystitis and
the two groups with hydrops and empyema of the gallbladder was not
statistically significant (p= 0.07). The complication
rates of acute cholecystitis, hydrops, empyema of the gallbladder, and
gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p= NS). Patients with an operative
delay of 96 hours or less from the onset of acute cholecystitis had a
conversion rate of 23%, whereas a delay of more than 96 hours was
associated with a conversion rate of 47% (p= 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in
the converted group (p= 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable
gallbladder, WBC count over 13,000/cc, and acute gangrenous
cholecystitis were independently associated with a high LC conversion
rate; male patients, finding large bile stones, serum bilirubin over
0.8 mg/dl, and WBC count over 13,000/cc were independently associated
with a high complication rate following laparoscopic surgery with or
without conversion. Generally, LC can be performed safely for acute
cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and
complication rates in selected cases. LC for acute cholecystitis should
be performed within 96 hours of the onset of disease. Predictors of
conversion and complications may be helpful when planning the
laparoscopic approach to acute cholecystitis.