Association of intra-operative adverse events with gall bladder wall thickness in patients undergoing laparoscopic cholecystectomy for acute calculous cholecystitis: A prospective study from a low middle income country

Objective: Acute calculous cholecystitis is one of the most common surgical infectious disease emergencies worldwide. Early laparoscopic cholecystectomy (LC) is the definitive treatment, but severe inflammation often leads to technical difficulty and increased intraoperative adverse events. This study evaluated preoperative gallbladder wall thickness (GWT) on ultrasound as a simple, objective predictor of difficult LC in acute calculous cholecystitis. Methodology: A prospective cross-sectional study was conducted in the Department of Surgery, Aga Khan University Hospital, Karachi, from May to November 2022. Consecutive adult patients (18–60 years) with ultrasound-confirmed acute calculous cholecystitis undergoing LC within 96 hours of symptom onset were included (n=116). GWT was classified as normal (≤3 mm), moderate (3.1–7 mm), and severe (>7 mm). Intraoperative adverse events recorded were operative time >90 minutes, distended gallbladder requiring aspiration, dense adhesions, conversion to open procedure, and drain placement. Results: Mean GWT was 3.44 ± 1.79 mm. Severe thickening (>7 mm) was present in six patients (5.2%) and was highly significantly associated with prolonged operative time (p<0.001), need for gallbladder aspiration (p<0.001), conversion to open cholecystectomy (p<0.001), and subhepatic drain placement (p<0.001). Dense adhesions showed a strong trend (p=0.069). Conclusion: Severe preoperative gallbladder wall thickening (>7 mm) is a powerful, reproducible marker of intense inflammation and can predicts difficult laparoscopic cholecystectomy in acute infectious cholecystitis. Routine reporting of GWT allows accurate risk stratification, facilitates early involvement of experienced surgeons, reduces conversion rates, and optimizes outcomes in this common infectious surgical emergency – making it a practical and cost-effective surgical solution, especially in low-middle-income settings.