Difficult Cholecystectomy for Acute Cholecystitis: Preoperative Risk Factors, Computed Tomography (CT) Findings, and Surgical Approach Selection in a Real-World Cohort

Background: Preoperative assessment of surgical difficulty is important in acute cholecystitis. Although laparoscopic cholecystectomy is the standard approach, real-world emergency surgery includes both laparoscopic and open cholecystectomy. This study evaluated preoperative factors associated with difficult cholecystectomy in a real-world surgical cohort. Methods: This single-center retrospective study included 282 patients who underwent cholecystectomy for acute cholecystitis between January 2017 and December 2022. Difficult cholecystectomy was defined using an approach-specific composite score consisting of operative time, intraoperative blood loss, surgery-related postoperative complications, and subtotal cholecystectomy. Preoperative computed tomography (CT) findings were evaluated using five predefined findings: gallbladder wall thickening ≥5 mm, poor wall enhancement, pericholecystic fat stranding ≥5 mm, intraluminal or intramural gas, and pericholecystic abscess formation. Results: Of the 282 patients, 79 (28.0%) were classified as having difficult cholecystectomy. In multivariable analysis, American Society of Anesthesiologists physical status ≥3 (odds ratio (OR), 2.25; 95% confidence interval (CI), 1.19-4.24; p = 0.012) and C-reactive protein level (OR, 1.04; 95% CI, 1.01-1.08; p = 0.015) were independently associated with difficult cholecystectomy. Positive CT findings showed a borderline association but did not reach statistical significance (OR, 1.86; 95% CI, 0.93-3.74; p = 0.082). Open cholecystectomy was more frequently selected for patients with severe clinical and inflammatory backgrounds, but severe complications and bile duct injury did not differ significantly between approaches. Conclusions: In this real-world cohort, difficult cholecystectomy was mainly associated with systemic inflammatory burden and patient condition, whereas CT findings provided complementary information on local inflammation. Open cholecystectomy was selected for more severe cases without an increase in severe complications or bile duct injury, suggesting that surgical approach selection may be an important component of safe management in severe acute cholecystitis.