Clinical–Histopathological Concordance of Surgical Triage and the Unexpected Acute Phenotype in 773 Consecutive Laparoscopic Cholecystectomies

Background and Objectives: Surgical triage and final histopathological classification do not always fully overlap. This study evaluated their concordance, the frequency of unexpected acute pathology among electively scheduled patients, and associated preoperative characteristics. Materials and Methods: This single-center, single-surgeon retrospective cohort included 773 patients whose cholecystectomy was completed laparoscopically between 1 January 2022 and 30 June 2026. Surgical triage was classified as emergency or elective, and histopathology as acute or chronic inflammatory pathology. “Unexpected acute pathology” denoted acute histopathology in electively scheduled patients, irrespective of clinical suspicion. Multivariable logistic regression was performed in 627 elective patients with complete data. Model A included previous biliary attack and preoperative radiological gallbladder wall thickening; Model B additionally included the C-reactive protein/albumin ratio (CAR). Results: Of 773 patients, 138 underwent emergency and 635 elective surgery. Observed agreement was 92.4%, with Cohen’s kappa of 0.757 (95% bootstrap confidence interval: 0.697–0.814). Unexpected acute pathology occurred in 42 elective patients (6.6%). In Model B, previous biliary attack (odds ratio [OR] = 2.76), preoperative radiological gallbladder wall thickening (OR = 4.09), and CAR (OR = 1.52 per 5-unit increase) were associated with unexpected acute pathology. Adding CAR increased the area under the receiver operating characteristic curve from 0.697 to 0.756 and improved model fit (p = 0.00055). Unexpected acute pathology occurred in 3.8%, 11.9%, and 37.5% of patients with 0, 1, and 2 findings, respectively (n = 477, 126, and 24). Across these strata, documented omental adhesions increased from 23.5% to 62.5% and postoperative hospital stay >1 day from 9.2% to 41.7%. Conclusions: Surgical triage showed high overall concordance with histopathology. The two preoperative findings were associated with unexpected acute pathology and a more complex perioperative profile; CAR provided complementary information. Given the small two-finding subgroup and single-center design, external validation is required before these findings can guide operative planning.