Acute cholecystitis is a common inflammatory condition of the gallbladder, most frequently resulting from obstruction of the cystic duct by gallstones. This obstruction leads to bile stasis, gallbladder distension, mucosal ischemia, and secondary bacterial infection, which together produce the classical clinical picture of right upper quadrant abdominal pain, fever, leukocytosis, and a positive Murphy’s sign. It accounts for a significant proportion of emergency surgical admissions worldwide and represents a major burden on healthcare systems, particularly in developing countries like India where gallstone disease is highly prevalent due to dietary habits, obesity, and increasing life expectancy. The standard treatment for acute cholecystitis has evolved significantly over the past few decades. Laparoscopic cholecystectomy, first introduced in the late 1980s, is now established as the gold standard for the management of symptomatic gallstone disease due to its advantages of reduced postoperative pain, shorter hospital stay, early return to normal activity, and better cosmetic outcomes compared to open surgery. However, the optimal timing of laparoscopic cholecystectomy in acute cholecystitis remains a topic of ongoing debate. Traditionally, patients with acute cholecystitis were managed with initial conservative treatment consisting of intravenous antibiotics, analgesics, and supportive care, followed by delayed (interval) laparoscopic cholecystectomy performed after 6–12 weeks. This strategy was based on the assumption that delaying surgery allows inflammation to subside, thereby reducing operative difficulty, conversion rates, and complications. However, several disadvantages of delayed surgery have been well documented, including recurrent attacks of cholecystitis, biliary colic, pancreatitis, repeated hospital admissions, and increased overall healthcare costs during the waiting period. In contrast, early laparoscopic cholecystectomy (ELC), defined as surgery performed within 72 hours of admission or during the index hospitalization, has gained increasing acceptance over recent years. Early intervention aims to remove the diseased gallbladder during the acute phase of inflammation, thereby preventing recurrent biliary events and reducing total treatment duration. With advances in laparoscopic expertise, improved imaging modalities, better perioperative antibiotics, and adherence to standardized guidelines, early surgery has become increasingly safe and feasible. Several international studies and systematic reviews have supported the superiority or at least equivalence of early laparoscopic cholecystectomy compared to delayed surgery. For example, a Cochrane review by Gurusamy et al. reported that early cholecystectomy reduces hospital stay without increasing complication rates compared to delayed surgery (Gurusamy KS et al., Cochrane Database Syst Rev, 2013). Similarly, the Tokyo Guidelines 2018 (TG18) strongly recommend early laparoscopic cholecystectomy for patients with mild to moderate acute cholecystitis when performed by experienced surgeons (Okamoto K et al., J Hepatobiliary Pancreat Sci, 2018). Indian studies have also demonstrated comparable findings. Kumar et al. reported that early laparoscopic cholecystectomy in acute cholecystitis is safe and associated with shorter hospital stay and reduced overall cost compared to delayed surgery (Kumar A et al., Journal of Minimal Access Surgery, 2020). Similarly, Singh et al. observed that early surgery does not significantly increase conversion rates or morbidity when performed within the index admission in tertiary care settings in India (Singh S et al., Indian Journal of Surgery, 2021). Despite growing evidence favoring early intervention, concerns still persist among surgeons regarding increased technical difficulty due to edematous and inflamed Calot’s triangle, obscured anatomical landmarks, and a perceived higher risk of bile duct injury. These concerns often lead to variation in clinical practice, especially in resource-limited settings and peripheral healthcare centers where laparoscopic expertise may vary. Given this ongoing debate and variability in clinical decision-making, it is essential to further evaluate and compare the outcomes of early versus delayed laparoscopic cholecystectomy in real-world clinical settings. Therefore, the present study was undertaken to assess and compare the perioperative and postoperative outcomes of early and delayed laparoscopic cholecystectomy in patients with acute cholecystitis in a tertiary care hospital in India, with special emphasis on operative safety, complication rates, duration of hospital stay, and overall treatment cost.

Study Design This was a prospective, comparative observational study conducted to evaluate and compare the outcomes of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in patients diagnosed with acute cholecystitis. Study Setting The study was carried out in the Department of General Surgery of a tertiary care teaching hospital in India, which serves as a referral center for both urban and rural populations. Study Duration The study was conducted over a period of 8 months, from January 2023 to August 2023. Study Population A total of 120 patients diagnosed with acute calculous cholecystitis were enrolled in the study after applying inclusion and exclusion criteria. Ethical Considerations Ethical clearance was obtained from the Institutional Ethics Committee. Written informed consent was taken from all participants prior to inclusion. Patient confidentiality was strictly maintained throughout the study Inclusion Criteria Patients were included if they met the following criteria: • Age between 18 and 70 years • Ultrasound-confirmed acute calculous cholecystitis • Diagnosis consistent with Tokyo Guidelines 2018 (mild to moderate severity) • Fit for general anesthesia • Presented within 7 days of symptom onset Exclusion Criteria Patients were excluded if they had: • Common bile duct stones (choledocholithiasis) • Gallbladder perforation or empyema • Severe acute cholecystitis requiring ICU care • Associated pancreatitis or cholangitis • Pregnancy • Severe cardiopulmonary comorbidities making them unfit for surgery • Previous upper abdominal surgery (to avoid confounding adhesions) Statistical Analysis Data were analyzed using chi-square test and Student’s t-test. A p-value < 0.05 was considered statistically significant. Study Design This was a prospective, comparative observational study conducted to evaluate and compare the outcomes of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in patients diagnosed with acute cholecystitis. Study Setting The study was carried out in the Department of General Surgery of a tertiary care teaching hospital in India, which serves as a referral center for both urban and rural populations. Study Duration The study was conducted over a period of 8 months, from January 2023 to August 2023. Study Population A total of 120 patients diagnosed with acute calculous cholecystitis were enrolled in the study after applying inclusion and exclusion criteria. Ethical Considerations Ethical clearance was obtained from the Institutional Ethics Committee. Written informed consent was taken from all participants prior to inclusion. Patient confidentiality was strictly maintained throughout the study Inclusion Criteria Patients were included if they met the following criteria: • Age between 18 and 70 years • Ultrasound-confirmed acute calculous cholecystitis • Diagnosis consistent with Tokyo Guidelines 2018 (mild to moderate severity) • Fit for general anesthesia • Presented within 7 days of symptom onset Exclusion Criteria Patients were excluded if they had: • Common bile duct stones (choledocholithiasis) • Gallbladder perforation or empyema • Severe acute cholecystitis requiring ICU care • Associated pancreatitis or cholangitis • Pregnancy • Severe cardiopulmonary comorbidities making them unfit for surgery • Previous upper abdominal surgery (to avoid confounding adhesions) Statistical Analysis Data were analyzed using chi-square test and Student’s t-test. A p-value < 0.05 was considered statistically significant.

Table 1: Demographic Profile of Patients Parameter ELC Group (n = 60) DLC Group (n = 60) p-value Mean age (years) 45.6 ± 12.3 47.1 ± 11.8 0.48 (NS) Age range (years) 19–68 21–70 - Male patients 26 (43.3%) 25 (41.7%) 0.84 (NS) Female patients 34 (56.7%) 35 (58.3%) Male: Female ratio 01:01.3 01:01.4 0.76 (NS) Diabetes mellitus 11 (18.3%) 12 (20.0%) 0.81 (NS) Hypertension 15 (25.0%) 14 (23.3%) 0.83 (NS) BMI (kg/m²) 26.2 ± 3.8 26.5 ± 4.1 0.67 (NS) Smokers 9 (15.0%) 10 (16.7%) 0.79 (NS) Alcohol use 7 (11.7%) 8 (13.3%) 0.77 (NS) The mean age of patients in the ELC group was 45.6 ± 12.3 years, while in the DLC group it was 47.1 ± 11.8 years, showing no statistically significant difference (p = 0.48). This indicates that both groups were age-matched, ensuring comparability of outcomes. Gender distribution revealed a slight female predominance in both groups, with females accounting for 56.7% in the ELC group and 58.3% in the DLC group. The male-to-female ratio was nearly similar in both groups (1:1.3 vs 1:1.4), reflecting the known higher prevalence of gallstone disease among females due to hormonal and metabolic factors. The prevalence of comorbid conditions such as diabetes mellitus and hypertension was also comparable between the two groups. Diabetes was present in 18.3% of the ELC group and 20% of the DLC group, while hypertension was observed in 25% and 23.3% respectively, with no statistically significant differences. Body Mass Index (BMI), an important factor influencing surgical difficulty and outcomes, was also similar in both groups (26.2 ± 3.8 vs 26.5 ± 4.1 kg/m²), indicating that both cohorts had comparable baseline nutritional status, predominantly falling in the overweight category. Lifestyle factors such as smoking and alcohol consumption were evenly distributed between the two groups and did not show any significant variation. The demographic profile demonstrates that both groups were well matched with respect to age, sex, comorbidities, BMI, and lifestyle risk factors. This comparability strengthens the validity of the study by minimizing selection bias and ensuring that differences in outcomes between early and delayed laparoscopic cholecystectomy are attributable to timing of surgery rather than baseline patient characteristics. Table 2: Intraoperative Outcomes Parameter ELC Group (n = 60) DLC Group (n = 60) p-value Mean operative time (minutes) 62.5 ± 15.4 68.2 ± 17.1 0.04 (S) Operative time range (min) 40–105 45–120 - Conversion to open surgery 5 (8.3%) 6 (10.0%) 0.74 (NS) Intraoperative blood loss (mL) 85 ± 30 92 ± 35 0.21 (NS) Gallbladder perforation 4 (6.7%) 5 (8.3%) 0.72 (NS) Bile duct injury 0 (0%) 1 (1.7%) 0.31 (NS) Difficult Calot’s dissection 12 (20.0%) 15 (25.0%) 0.51 (NS) The mean operative time was 62.5 ± 15.4 minutes in the ELC group compared to 68.2 ± 17.1 minutes in the DLC group, showing a statistically significant shorter operative duration in the early surgery group (p = 0.04). This may be attributed to the absence of dense fibrotic adhesions typically seen in delayed cases, where chronic inflammatory changes can make dissection more technically demanding. The conversion rate to open cholecystectomy was slightly lower in the ELC group (8.3%) compared to the DLC group (10%), although this difference was not statistically significant (p = 0.74). Conversion was primarily required due to dense adhesions, unclear anatomy in Calot’s triangle, and uncontrolled bleeding. Intraoperative blood loss was comparable between the two groups, with a mean blood loss of 85 ± 30 mL in the ELC group and 92 ± 35 mL in the DLC group (p = 0.21), indicating no significant difference in surgical safety between early and delayed approaches. Gallbladder perforation occurred in 6.7% of ELC patients and 8.3% of DLC patients, which was not statistically significant. These perforations were mostly managed intraoperatively without major complications. Bile duct injury was rare and occurred in only one patient in the DLC group, while none were observed in the ELC group. Although this difference was not statistically significant, it highlights the importance of careful dissection and adherence to the Critical View of Safety technique. Difficult dissection of Calot’s triangle was encountered in 20% of ELC cases and 25% of DLC cases, reflecting the inflammatory nature of the disease in both groups. However, this difference was not statistically significant. The intraoperative outcomes demonstrate that early laparoscopic cholecystectomy is not associated with increased technical difficulty or higher complication rates compared to delayed surgery. In fact, operative time was significantly shorter in the early group, and other parameters such as conversion rate, blood loss, and bile duct injury were comparable between the two groups. These findings suggest that early surgery is not only safe but may also be technically more favorable in selected patients when performed by experienced surgeons. The results further support the growing evidence that delay in surgery does not necessarily simplify the procedure and may, in some cases, lead to more fibrotic changes and increased operative difficulty. Table 3: Postoperative Outcomes Parameter ELC Group (n = 60) DLC Group (n = 60) p-value Overall complications 6 (10.0%) 13 (21.6%) 0.04 (S) Surgical site infection (SSI) 3 (5.0%) 7 (11.6%) 0.18 (NS) Bile leak 1 (1.7%) 2 (3.3%) 0.55 (NS) Postoperative fever 4 (6.7%) 8 (13.3%) 0.18 (NS) Mean VAS pain score (24 hrs) 3.4 ± 1.1 4.6 ± 1.3 0.002 (S) Mean hospital stay (days) 5.2 ± 1.4 10.8 ± 2.3 <0.001 (HS) Wound infection requiring drainage 2 (3.3%) 5 (8.3%) 0.24 (NS) Readmission rate 2 (3.3%) 8 (13.3%) 0.03 (S) The overall postoperative complication rate was significantly lower in the ELC group (10.0%) compared to the DLC group (21.6%) (p = 0.04). This indicates better postoperative recovery and fewer adverse events in patients undergoing early surgery. Surgical site infection (SSI) occurred in 5.0% of ELC patients and 11.6% of DLC patients, although this difference was not statistically significant (p = 0.18). Most infections were superficial and managed with antibiotics and local wound care. Bile leak, a serious but rare complication, was observed in 1 patient (1.7%) in the ELC group and 2 patients (3.3%) in the DLC group, with no statistically significant difference (p = 0.55). All cases were managed conservatively with drainage and supportive care. Postoperative fever was slightly more common in the DLC group (13.3%) compared to the ELC group (6.7%), though this difference did not reach statistical significance. Fever was mostly self-limiting and related to inflammatory response or minor wound infection. Pain assessment using the Visual Analog Scale (VAS) at 24 hours post-surgery showed significantly lower pain scores in the ELC group (3.4 ± 1.1) compared to the DLC group (4.6 ± 1.3) (p = 0.002). This suggests faster recovery and better early postoperative comfort in patients undergoing early surgery. The mean hospital stay was significantly shorter in the ELC group (5.2 ± 1.4 days) compared to the DLC group (10.8 ± 2.3 days) with high statistical significance (p < 0.001). This reduction in hospitalization reflects one of the major advantages of early laparoscopic cholecystectomy, contributing to lower healthcare burden and improved bed utilization. Wound infection requiring drainage was observed in a small proportion of patients in both groups, with slightly higher incidence in the DLC group (8.3%) compared to ELC group (3.3%), although this was not statistically significant. The readmission rate was significantly higher in the DLC group (13.3%) compared to the ELC group (3.3%) (p = 0.03). Readmissions in the delayed group were mainly due to recurrent biliary colic, acute cholecystitis episodes, and biliary complications during the waiting period for elective surgery. The postoperative outcomes clearly demonstrate the superiority of early laparoscopic cholecystectomy in terms of faster recovery, lower overall complication rates, reduced postoperative pain, shorter hospital stay, and fewer readmissions. The higher complication and readmission rates in the delayed group highlight the clinical disadvantage of postponing definitive surgical management, as patients remain at risk for recurrent attacks and disease progression during the waiting period. Overall, early laparoscopic cholecystectomy provides better postoperative recovery and improved patient satisfaction without increasing the risk of major complications, supporting its role as the preferred treatment strategy in acute cholecystitis. Table 4: Economic Outcome Parameter ELC DLC p-value Mean total cost (INR) Lower Higher <0.01 Readmission rate 3% 13% 0.03 The economic outcome analysis in this study was performed to evaluate the overall cost-effectiveness of Early Laparoscopic Cholecystectomy (ELC) compared with Delayed Laparoscopic Cholecystectomy (DLC) in patients with acute cholecystitis. The assessment included direct medical costs such as hospital stay, medications, investigations, and operative expenses, as well as indirect costs related to readmissions and loss of productivity.

Acute cholecystitis is a common surgical emergency caused predominantly by cystic duct obstruction due to gallstones, leading to gallbladder inflammation. The optimal timing of laparoscopic cholecystectomy—early versus delayed—remains an important clinical question despite widespread acceptance of laparoscopic surgery as the gold standard for gallstone disease. In the present study, both Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) groups were comparable in baseline characteristics, ensuring valid outcome comparison. Similar demographic profiles have been reported in Indian studies by Kumar et al. (2020) and Singh et al. (2021), where female predominance and middle-aged presentation were commonly observed, reflecting the epidemiology of gallstone disease. The present study showed that mean operative time was significantly shorter in the ELC group compared to DLC, while conversion rates to open surgery and intraoperative complications were comparable. These findings are consistent with the Cochrane systematic review by Gurusamy et al. (2013), which concluded that early cholecystectomy does not increase operative complications or conversion rates compared with delayed surgery. Similarly, the Tokyo Guidelines 2018 (Okamoto et al., 2018) recommend early laparoscopic cholecystectomy in mild to moderate acute cholecystitis when performed by experienced surgeons, emphasizing safety and feasibility. Although delayed surgery has traditionally been considered technically easier due to resolution of inflammation, several studies suggest that fibrosis and chronic adhesions formed during the waiting period may actually increase surgical difficulty, which may explain the slightly longer operative time observed in the DLC group. The present study demonstrated significantly better postoperative outcomes in the ELC group, including lower overall complication rates, reduced postoperative pain, shorter hospital stay, and lower readmission rates. A major finding was the significantly reduced hospital stay in the ELC group, which is consistent with multiple meta-analyses and randomized trials, including Gurusamy et al. (2013), which reported shorter total hospital stay in early surgery without increasing morbidity. This reduction is clinically important as it decreases healthcare burden and improves bed turnover, particularly in high-volume hospitals. Postoperative pain scores were significantly lower in the ELC group. This finding may be explained by earlier resolution of the inflammatory process through definitive surgery, preventing recurrent episodes of biliary colic and inflammation that are commonly seen in delayed management. The readmission rate was significantly higher in the DLC group, mainly due to recurrent biliary colic and recurrent acute cholecystitis during the waiting period. This finding is strongly supported by studies such as de Mestral et al. and other observational analyses, which have demonstrated that delayed surgery is associated with a higher risk of recurrent biliary events before definitive treatment. One of the most important findings of the present study is the significantly lower overall treatment cost in the ELC group compared to the DLC group. Early surgery reduced direct medical costs (hospital stay, medications, and investigations) as well as indirect costs (loss of productivity and wages). Similar cost-effectiveness findings have been reported in Indian studies by Kumar et al. (2020, Journal of Minimal Access Surgery) and Sharma et al. (2022, Indian Journal of Surgery), both of which concluded that early laparoscopic cholecystectomy significantly reduces overall healthcare expenditure. The Tokyo Guidelines 2018 also indirectly support early intervention by emphasizing reduced hospitalization and improved resource utilization with early surgery. In resource-limited countries like India, these economic advantages are particularly relevant for healthcare policy and hospital management. The findings of this study are in strong agreement with the Tokyo Guidelines 2018 (TG18), which recommend early laparoscopic cholecystectomy for patients with mild to moderate acute cholecystitis when surgical expertise is available (Okamoto et al., 2018). TG18 highlights that early surgery reduces hospital stay, prevents recurrent attacks, and does not increase complication rates. Furthermore, the Cochrane review by Gurusamy et al. (2013) provides high-level evidence that early surgery is safe and associated with better overall outcomes compared to delayed surgery.

Early laparoscopic cholecystectomy is safe, feasible, and superior to delayed surgery in patients with acute cholecystitis. It reduces hospital stay, lowers overall cost, and decreases recurrence of symptoms without increasing operative complications. It should be preferred as first-line surgical management in appropriately selected patients.

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