In a hemodynamically stable patient with perforated acalculous cholecystitis (evidence of free fluid, peritonitis, or a contained bile leak), what is the preferred management?

Management of Hemodynamically Stable Perforated Acalculous Cholecystitis

In hemodynamically stable patients with perforated acalculous cholecystitis, immediate laparoscopic cholecystectomy should be performed as the definitive treatment, as early surgical intervention substantially decreases morbidity and mortality rates associated with gallbladder perforation. 1

Rationale for Immediate Surgery

• Gallbladder perforation carries mortality rates of 12-16%, and delayed surgical intervention is associated with elevated morbidity and mortality rates, increased likelihood of ICU admission, and prolonged post-operative hospitalization. 1

• Early diagnosis and immediate surgical intervention are critical because perforation is rarely diagnosed pre-operatively, and the presentation mimics uncomplicated acute cholecystitis. 1

• For Type I perforations (free perforation with generalized peritonitis) and Type II perforations (pericholecystic abscess with localized peritonitis), prompt surgical management is essential. 1

Surgical Approach Selection

Laparoscopic vs. Open Approach

• Laparoscopic cholecystectomy is the preferred initial approach for stable patients with perforated acalculous cholecystitis, as it is safe and effective for acute cholecystitis when performed by experienced surgeons. 1

• Early laparoscopic cholecystectomy has comparable surgical outcomes to percutaneous drainage followed by delayed surgery, but with significantly shorter hospital stays. 2

• Conversion to open cholecystectomy should be performed without hesitation in cases of severe local inflammation, adhesions, bleeding from Calot's triangle, or suspected bile duct injury—conversion is not a failure but a valid safety option. 1

Technical Considerations for Difficult Cases

• When the critical view of safety cannot be obtained due to severe inflammation or perforation, subtotal cholecystectomy is recommended as it achieves comparable morbidity rates to total cholecystectomy while avoiding bile duct injuries. 1

• Subtotal cholecystectomy is specifically indicated for empyema or perforated gallbladder (6.1% of cases in large series), with no bile duct injuries reported in the subtotal approach compared to four injuries in matched complete cholecystectomy cases. 1

When Percutaneous Cholecystostomy is NOT Appropriate

• Percutaneous cholecystostomy should NOT be the primary treatment in stable patients with perforation, as it is reserved only for critically ill patients with multiple comorbidities who are unfit for surgery. 1

• While percutaneous cholecystostomy may serve as definitive treatment in 80% of acalculous cholecystitis cases without perforation, the presence of perforation or gallbladder gangrene is an absolute indication for cholecystectomy rather than drainage alone. 3, 4

• In the specific context of perforated gallbladder, early laparoscopic cholecystectomy should be considered the optimal treatment, with percutaneous drainage reserved only for patients carrying prohibitively high operative risk. 2

Timing of Intervention

• Surgery should be performed as soon as possible once the diagnosis is established, ideally within 7 days of hospital admission and within 10 days of symptom onset if this represents the initial presentation. 1

• The presence of free fluid, peritonitis, or contained bile leak in a stable patient does not justify delayed management—these findings mandate urgent surgical intervention. 1

Critical Pitfalls to Avoid

• Do not delay surgery hoping for clinical improvement with antibiotics alone—perforation requires source control, and delayed intervention dramatically increases mortality. 1

• Do not assume that acalculous cholecystitis can be managed conservatively when perforation is present; this is fundamentally different from uncomplicated acalculous cholecystitis where conservative management may be appropriate. 3

• Do not rely on ultrasound alone for diagnosis—CT scan is more reliable in demonstrating the gallbladder wall defect, pericholecystic collection, and free intraperitoneal fluid that characterize perforation. 1

• Ensure adequate surgical expertise is available, as perforated cholecystitis represents a technically challenging case; referral to high-volume centers should be considered if local expertise is limited. 1