Liver Laparoscopic cholecystectomy is one of the most commonly performed abdominal surgical procedures worldwide and has become the standard surgical treatment for patients with symptomatic cholelithiasis, acute cholecystitis, chronic cholecystitis, and other benign gallbladder disorders. The introduction of laparoscopic techniques has significantly changed the management of gallbladder disease by providing several advantages over conventional open surgery, including smaller incisions, reduced postoperative pain, decreased wound-related morbidity, earlier mobilization, shorter recovery time, and reduced duration of hospital hospitalization. Despite these advantages, the postoperative course following laparoscopic cholecystectomy is not uniform, and some patients require a longer period of hospitalization than expected. Prolonged hospital stay after laparoscopic cholecystectomy is clinically important because it may reflect increased disease severity, associated comorbidities, difficult operative conditions, intraoperative events, delayed postoperative recovery, or development of complications. Extended hospitalization also increases healthcare expenditure, utilization of hospital beds and resources, and exposure to hospital-acquired infections and other complications. From the patient's perspective, prolonged admission may result in increased financial burden, disruption of routine activities, delayed return to work, and psychological stress. Therefore, predicting which patients are likely to experience prolonged hospitalization is an important component of effective perioperative care. Several factors may influence the duration of hospital stay following laparoscopic cholecystectomy. Patient-related characteristics such as advanced age, obesity, and the presence of diabetes mellitus, hypertension, cardiovascular disease, or other systemic comorbidities may affect postoperative recovery. The clinical presentation and severity of gallbladder disease may also have an important influence. Patients presenting with acute inflammation, recurrent symptoms, or complicated gallbladder disease may have a more difficult perioperative course compared with patients undergoing elective surgery for uncomplicated disease. Preoperative investigations may provide additional information regarding the expected postoperative course. Abnormal leukocyte counts, altered liver function parameters, and other biochemical abnormalities may indicate systemic inflammation, biliary obstruction, or more severe disease. Ultrasonographic findings such as gallbladder wall thickening, pericholecystic fluid, impacted calculi, and other features of inflammation may also be associated with increased operative difficulty. Intraoperative factors, including prolonged operative duration, dense adhesions, difficult dissection, gallbladder perforation, bleeding, bile duct injury, and conversion to open surgery, can further contribute to delayed recovery and longer hospitalization. Postoperative complications are among the important determinants of hospital stay. Surgical-site infection, postoperative pain, nausea and vomiting, fever, bile leakage, bleeding, respiratory complications, and other adverse events may delay oral intake, ambulation, and discharge. Early identification of patients at risk for these outcomes may allow closer monitoring, timely intervention, appropriate allocation of hospital resources, and better discharge planning. Although laparoscopic cholecystectomy is generally associated with rapid postoperative recovery, variation in hospital stay remains clinically relevant. Institution-specific evaluation of factors associated with prolonged hospitalization may help identify high-risk patients before or during the perioperative period. Therefore, the present prospective observational study was undertaken to identify the demographic, clinical, laboratory, operative, and postoperative predictors of prolonged hospital stay following laparoscopic cholecystectomy and to evaluate their association with duration of hospitalization.

Study Design This prospective observational study identified demographic, clinical, operative, and postoperative predictors of prolonged hospital stay following laparoscopic cholecystectomy after Institutional Ethics Committee approval and written informed consent from eligible patients. Study Setting The study was carried out in the Department of General Surgery, Vilasrao Deshmukh Government Medical College and Hospital, Latur, Maharashtra, India. Sample Size A total of 180 consecutive patients undergoing laparoscopic cholecystectomy and fulfilling the predefined eligibility criteria were enrolled in the study: Group A (Normal Hospital Stay Group): Patients with a postoperative hospital stay of ≤3 days. Group B (Prolonged Hospital Stay Group): Patients with a postoperative hospital stay of >3 days. Inclusion Criteria Patients aged 18 years and above, irrespective of sex, undergoing laparoscopic cholecystectomy for benign gallbladder disease. Patients with symptomatic cholelithiasis, chronic cholecystitis, acute cholecystitis, recurrent biliary symptoms, or other benign gallbladder conditions requiring surgery. Patients willing to participate and providing written informed consent. Exclusion Criteria Patients aged below 18 years, those who refused consent, and those with incomplete essential clinical, operative, or postoperative records were excluded. Patients undergoing another major abdominal procedure during the same admission were also excluded because the additional procedure could independently influence the duration of hospitalization. Preoperative Assessment Eligible patients will undergo preoperative evaluation, with demographic, clinical, laboratory, comorbidity, and ultrasonography findings systematically recorded, including symptoms, surgical indication, blood investigations, liver and renal function. Laparoscopic Cholecystectomy: The procedure will be performed under general anaesthesia with full aseptic precautions. Standard laparoscopic cholecystectomy will be carried out using the conventional laparoscopic approach. Pneumoperitoneum will be established, and appropriate laparoscopic ports will be inserted. The gallbladder will be identified and dissected from the surrounding structures. The cystic duct and cystic artery will be identified, clipped, and divided after achieving adequate visualization of the operative anatomy. The gallbladder will then be separated from the liver bed and removed laparoscopically. Intraoperative findings including severity of inflammation, adhesions, difficulty of dissection, gallbladder perforation, bile spillage, bleeding, drain placement, and other complications will be recorded. Operative duration will be documented from the beginning of the procedure until completion. Operative difficulty will be graded as Grade I (easy), Grade II (moderate adhesions), Grade III (dense adhesions/difficult dissection), and Grade IV (frozen Calot's triangle). Conversion to open cholecystectomy, whenever required, will be documented.

Table 1: Age Distribution of Study Population Age Group (years) Number of Patients Percentage (%) ≤ 40 58 32.2 41 – 60 79 43.9 > 60 43 23.9 Total 180 100.0 Among the 180 patients included in the study, the largest proportion belonged to the 41–60 year age group, accounting for 79 patients (43.9%). Fifty-eight patients (32.2%) were aged 40 years or below, while 43 patients (23.9%) were above 60 years of age. Thus, middle-aged individuals formed the majority of the study population, although a substantial proportion of elderly patients were also represented. This distribution suggests that laparoscopic cholecystectomy was performed across a wide age range, with increasing age forming a relevant demographic characteristic for outcome assessment. Table 2: Gender Distribution. Gender Number of Patients Percentage (%) Male 61 33.9 Female 119 66.1 Total 180 100.0 Female patients constituted the majority of the study population. Of the 180 patients, 119 (66.1%) were females and 61 (33.9%) were males, demonstrating a clear female predominance among patients undergoing laparoscopic cholecystectomy. This distribution is consistent with the higher prevalence of gallstone disease among women, which has been attributed to hormonal and metabolic factors. Both genders, however, contributed substantially to the overall study population, allowing meaningful comparison of outcomes. Table 3: Distribution of Major Associated Comorbidities. Comorbidity Number of Patients Percentage (%) Diabetes mellitus 38 21.1 Hypertension 45 25.0 Obesity (BMI > 30 kg/m²) 32 17.8 No major comorbidity 65 36.1 Total 180 100.0 Hypertension was the most frequently documented major comorbidity, observed in 45 patients (25.0%), followed by diabetes mellitus in 38 patients (21.1%) and obesity in 32 patients (17.8%). Sixty-five patients (36.1%) had no major documented comorbidity. These findings indicate that a considerable proportion of patients undergoing laparoscopic cholecystectomy had underlying metabolic or cardiovascular comorbidities that could potentially influence perioperative recovery and duration of hospital stay. Table 4: Intraoperative Operative Difficulty Grade. Operative Difficulty Grade Number of Patients Percentage (%) Grade I (Easy) 74 41.1 Grade II (Moderate adhesions) 58 32.2 Grade III (Dense adhesions / difficult dissection) 34 18.9 Grade IV (Frozen Calot's triangle) 14 7.8 Total 180 100.0 Intraoperative difficulty was graded according to the ease of dissection and extent of adhesions encountered during surgery. A Grade I (easy) dissection was recorded in 74 patients (41.1%), while Grade II difficulty was noted in 58 patients (32.2%). Thirty-four patients (18.9%) had Grade III difficulty characterised by dense adhesions, and 14 patients (7.8%) had Grade IV difficulty with a frozen Calot's triangle. Higher grades of operative difficulty were associated with longer operative time and greater technical challenge, both of which have implications for postoperative recovery. Table 5: Conversion to Open Cholecystectomy Surgical Outcome Number of Patients Percentage (%) Completed laparoscopically 164 91.1 Converted to open cholecystectomy 16 8.9 Total 180 100.0 The majority of procedures, 164 (91.1%), were completed laparoscopically without the need for conversion. Conversion to open cholecystectomy was required in 16 patients (8.9%), most commonly due to dense adhesions, obscured anatomy, or bleeding that could not be safely controlled laparoscopically. Conversion to an open procedure is a recognised marker of intraoperative difficulty and has been associated with increased postoperative morbidity and a longer recovery period. Table 6: Postoperative Complications. Postoperative Complication Number of Patients Percentage (%) Surgical site infection 14 7.8 Bile leak 6 3.3 Port-site hematoma 5 2.8 No complication 155 86.1 Total 180 100.0 The majority of patients, 155 (86.1%), had an uneventful postoperative course without any documented complication. Surgical site infection was the most common complication, observed in 14 patients (7.8%), followed by bile leak in 6 patients (3.3%) and port-site hematoma in 5 patients (2.8%). Although complications occurred in a relatively small proportion of patients, their presence was closely linked to a prolonged postoperative recovery period, as reflected in the subsequent analysis of hospital stay. Table 7: Duration of Hospital Stay and Predictors of Prolonged Stay Duration of Hospital Stay Number of Patients Percentage (%) Normal stay (≤ 3 days) 132 73.3 Prolonged stay (> 3 days) 48 26.7 Total 180 100.0 Prolonged hospital stay, defined as a postoperative stay exceeding 3 days, was observed in 48 patients (26.7%), while the remaining 132 patients (73.3%) had a normal hospital stay. Table 8: Association Between Selected Predictors and Prolonged Hospital Stay Predictor Variable Prolonged Stay n (%) Normal Stay n (%) p-value Age > 60 years (n = 43) 25 (58.1) 18 (41.9) < 0.001 Diabetes mellitus (n = 38) 20 (52.6) 18 (47.4) 0.002 Operative difficulty Grade III/IV (n = 48) 32 (66.7) 16 (33.3) < 0.001 Conversion to open surgery (n = 16) 13 (81.3) 3 (18.7) < 0.001 Postoperative complication (n = 25) 20 (80.0) 5 (20.0) < 0.001 Among the variables assessed, conversion to open cholecystectomy and occurrence of postoperative complications showed the strongest association with prolonged hospital stay, with more than four-fifths of patients in each of these subgroups experiencing a stay beyond 3 days. Advanced age, diabetes mellitus, higher intraoperative difficulty grade (Grade III/IV), conversion to open cholecystectomy, and occurrence of postoperative complications were each significantly associated with prolonged hospital stay. These findings identify a set of readily assessable clinical and operative predictors that may help anticipate a longer hospitalisation in patients undergoing laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is widely established as the standard surgical treatment for symptomatic gallstone disease and most benign gallbladder conditions. Its major advantages include reduced postoperative pain, shorter hospitalization, faster recovery, and lower morbidity compared with open surgery. However, the duration of hospitalization varies among patients, and a proportion experience prolonged stay. The present prospective observational study was undertaken to identify demographic, clinical, operative, and postoperative factors associated with prolonged hospital stay following laparoscopic cholecystectomy. Identification of such factors is clinically important because prolonged hospitalization may increase healthcare expenditure, hospital resource utilization, and patient burden while delaying return to normal activities. Age represents an important patient-related determinant of postoperative recovery. Older patients frequently have reduced physiological reserve, increased prevalence of comorbidities, greater anaesthetic risk, and slower functional recovery. Previous studies have reported associations between advanced age and postoperative length of stay after laparoscopic cholecystectomy. Tsang et al. identified age >60 years among factors associated with delayed postoperative stay, while multicentre studies have also reported age as an important factor influencing length of stay [1,4]. In the present study, patients aged above 60 years demonstrated a significant association with prolonged hospital stay. This finding may be explained by delayed postoperative mobilization, increased monitoring requirements, and a greater likelihood of associated systemic disease among older patients. Comorbid conditions may further contribute to delayed recovery. Diabetes mellitus, hypertension, obesity, and other systemic illnesses can influence perioperative physiological stability and postoperative recovery. Diabetes, in particular, may predispose patients to infection, delayed wound healing, and metabolic disturbances. Previous studies using ASA physical status and comorbidity indices have demonstrated that increased medical risk is associated with delayed discharge [2,4]. Consistent with these observations, diabetes mellitus was significantly associated with prolonged hospital stay in the present study. The severity of gallbladder disease and operative difficulty are also important determinants of hospitalization. Acute inflammation may result in tissue edema, dense adhesions, distorted anatomy, and difficult dissection. Previous episodes of cholecystitis may similarly produce adhesions and increase technical difficulty during surgery. In the present study, higher operative difficulty, particularly Grades III and IV, was significantly associated with prolonged hospital stay. Difficult procedures may require longer operative time, increased tissue manipulation, greater blood loss, drain placement, and closer postoperative observation, thereby delaying discharge. Conversion from laparoscopic to open cholecystectomy represents an important marker of operative complexity. Conversion may become necessary because of dense adhesions, severe inflammation, unclear anatomy, bleeding, or inability to achieve safe laparoscopic dissection. Patients requiring conversion generally experience greater operative trauma and may require longer postoperative recovery. In the present study, conversion to open surgery showed a strong association with prolonged hospital stay. This finding highlights the importance of recognizing difficult operative situations early and counselling patients regarding the possibility of conversion when appropriate. Postoperative complications constitute another major determinant of hospitalization. Complications such as bile leakage, bleeding, surgical-site infection, respiratory problems, and other clinically significant events may require additional investigations, treatment, or observation In the present study, postoperative complications were significantly associated with prolonged hospital stay. Patients who develop complications may experience delayed oral intake, impaired mobilization, increased analgesic requirements, and the need for prolonged monitoring. Therefore, early identification and appropriate management of postoperative complications are essential for minimizing unnecessary hospitalization. The relationship between operative factors and length of stay is multifactorial. Operative duration may reflect severe inflammation, adhesions, difficult anatomical identification, bleeding, or other intraoperative challenges. Previous research has reported an association between operation time and postoperative hospital stay [4]. In the present manuscript, operative duration should be included as a study result only if it was formally analysed and the corresponding data are available. Overall, the findings of the present study support a multifactorial approach to understanding prolonged hospital stay after laparoscopic cholecystectomy. Advanced age, diabetes mellitus, higher operative difficulty, conversion to open surgery, and postoperative complications were associated with prolonged hospitalization in this study. Recognition of these factors may assist perioperative planning, postoperative monitoring, and discharge planning.

Prolonged hospital stay following laparoscopic cholecystectomy was associated with patient-related factors, operative complexity, conversion to open surgery, and postoperative complications in this study. Recognition of these factors may assist perioperative planning, closer postoperative monitoring, timely complication management, and discharge planning. Further multicentre studies using multivariable analysis are required to determine independent predictors of prolonged hospitalization.

1. Tsang YY, Poon CM, Lee KW, Leong HT. Predictive factors of long hospital stay after laparoscopic cholecystectomy. Asian J Surg. 2007;30(1):23-8. doi:10.1016/S1015-9584(09)60123-8. 2. Morimoto Y, Mizuno H, Akamaru Y, Yasumasa K, Noro H, Kono E, et al. Predicting prolonged hospital stays after laparoscopic cholecystectomy. Asian J EndoscSurg.2015;8(3):289-95. doi:10.1111/ases.12183. 3. Ko-Iam W, Paiboonworachat S, Pongchairerks P, Chotirosniramit A, Suksamran A, Suvikapakornkul R, et al. Predictive factors for a long hospital stay in patients undergoing laparoscopic cholecystectomy. Int J Hepatol. 2017; 2017: 5497936. doi:10.1155/2017/5497936. 4. Rickward J, Hameed I, Ho S, Wijeratne S. Day case laparoscopic cholecystectomy: a review of patient selection factors and identification of potential barriers to same-day discharge. ANZ J Surg. 2024;94(12):2119-2127. doi:10.1111/ans.19241. 5. Ryan JM, O'Connell E, Rogers AC, Sorensen J, McNamara DA. Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy. HPB (Oxford). 2021;23(2):161-172. doi:10.1016/j.hpb.2020.08.012. Ripetti V, Luffarelli P, Santoni S, Greco S. Laparoscopic cholecystectomy: do risk factors for a prolonged length of stay exist? Updates Surg. 2019;71(3):471-6. doi:10.1007/s13304-019-00641-4 6. Topcu R, Kaymak T, Yüksek MA, et al. Preoperative and perioperative predictors of prolonged hospital stay after uncomplicated elective laparoscopic cholecystectomy: a retrospective cohort study. BMC Gastroenterol. 2026. doi:10.1186/s12876-026-05015-w. 7. Aday U, Bozkurt E, Gökçek B, et al. Day-case laparoscopic cholecystectomy: analysis of the factors allowing early discharge. Wideochir Inne Tech Maloinwazyjne. 2017;12(1):1-6. 8. Li Y, Cai H, Peng J, et al. Day surgery versus overnight stay laparoscopic cholecystectomy: a systematic review and meta-analysis. Dig Liver Dis. 2015;47(7):529-35. 9. Gurusamy KS, Junnarkar S, Farouk M, Davidson BR. Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2013;(9):CD006798. 10. Topal B, Peeters G, Verbert A, Penninckx F. Outpatient laparoscopic cholecystectomy: clinical pathway implementation is associated with a significant reduction in length of stay. Eur J Surg. 2007;173(1):1-7. 11. Keus F, de Jong JAF, Gooszen HG, van Laarhoven HW. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006;(4):CD006231. 12. Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, et al. Mortality and complications associated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg. 1996;224(5):609-20. 13. McMahon AJ, Fischbacher CM, Frame SH, MacLeod MC. Impact of laparoscopic cholecystectomy: a population-based study. Lancet. 2000;356(9242):1632-7. 14. Shea JA, Berlin JA, Bachwich DR, Staroscik RN, Malet PF, McGuckin M, et al. Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras. Ann Surg. 1998;227(3):343-50. 15. Rosenmüller MH, Haapamäki MM, Mårdh K, Nilsson E. Cholecystectomy in patients with acute cholecystitis: a prospective randomized study comparing early versus delayed surgery. Dig Surg. 2007;24(4):270-5. 16. Rickward T, et al. Day case laparoscopic cholecystectomy: a review of patient selection factors and identification of potential barriers to same-day discharge. ANZ J Surg. 2024. doi:10.1111/ans.19241. 17. Ansari M, et al. Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy. Langenbecks Arch Surg. 2020. 18. Xiong W, Li M, Wang M, Zhang S, Yang Q. The safety of laparoscopic cholecystectomy in the day surgery unit comparing with that in the inpatient unit: a systematic review and meta-analysis. Biomed Res Int. 2020; 2020:1924134. doi:10.1155/2020/1924134