LAPAROSCOPIC CHOLECYSTECTOMY IN COMPLICATED ACUTE CHOLECYSTITIS: CURRENT EVIDENCE ON SAFETY, TECHNICAL CHALLENGES, AND SURGICAL OUTCOMES

Abstract

Acute cholecystitis is one of the major complications of gallstone disease and may progress to complicated forms characterized by severe inflammation, necrosis, gangrene, empyema, or perforation, conditions that increase the technical complexity of treatment and the risk of adverse events. Given the advances in minimally invasive surgery and the consolidation of strategies aimed at preventing bile duct injuries, this study aimed to conduct a narrative review of the literature on laparoscopic cholecystectomy for complicated acute cholecystitis, with emphasis on safety, technical challenges, timing of intervention, and major surgical outcomes. This descriptive and qualitative narrative review was conducted using PubMed/MEDLINE, Scopus, Web of Science, Embase, and SciELO, including clinical trials, observational studies, systematic reviews, meta-analyses, and guidelines published between 2020 and 2026 in Portuguese and English. The findings demonstrated that laparoscopic cholecystectomy remains the standard surgical approach even in complicated presentations, provided that its performance is guided by the patient's clinical condition, anatomical complexity, and established principles of operative safety. Severe inflammation, adhesions, necrosis, and fibrosis may impair the identification of hepatobiliary structures and hinder achievement of the critical view of safety, requiring the timely adoption of bailout strategies, particularly subtotal cholecystectomy and, in selected cases, conversion to open surgery. Regarding the timing of intervention, current evidence supports cholecystectomy during the index hospitalization in appropriately selected patients, with reduced length of hospital stay and no consistent increase in major complications compared with delayed surgery. Nevertheless, challenges remain regarding the heterogeneity of complicated presentations, the establishment of objective criteria for selecting bailout strategies, and the optimal timing of intervention in patients at higher perioperative risk. In conclusion, the surgical management of complicated acute cholecystitis should balance early intervention with operative safety, based on individualized patient selection, recognition of the limits of safe dissection, and adaptation of the surgical technique to intraoperative findings, with the aim of reducing complications and improving surgical outcomes.