title: The best timing of surgery in laparoscopic cholecystectomy for acute cholecystitis: when and how is to be performed.
abstract: OBJECTIVE
  In the treatment of acute cholecystitis the optimal timing of operation, regardless of whether performed laparoscopically or conventionally, is of major importance and not yet well defined feature among the different authors. We report our study on the timing of surgery in a consecutive series of 133 patients.
  
  
  METHODS
  The surgical technique consists in a partially downwards cholecystectomy from the infundibulum to the cystic duct. The dissection never involves the Calot Triangle's structures; this provides a safe and effective way to prevent major complications procedure related. Length of time interval from the onset of symptoms to surgery (ST measured in hours) and operating time (OT measured in minutes) have been recorded and analyzed to find out how these two variables are each other linked and what is the best timing for surgery. We also split the series taking a progressively increasing of ST as a cut off point and analyzed the two derived subgroups to outline which was the time of surgery (period of ST) that provided the best result in term of worsening of laparoscopic procedure difficulty.
  
  
  RESULTS
  51.3 hrs of average time between the onset of symptoms and surgery has been reported, with minimum of 24 hrs and maximum of 90 hrs, and median value of 48 hrs. The curve fit analysis on the scatterplot of the variable ST (independent) and OT (dependent) shows that these two variables are directly each other linked. The best division of the series was at the cut off of 57 hrs; each subgroup reached a statistical correlation coefficient: the late subgroup (the one over the cut off time of 57 hrs) had a twofold operating time increasing respect to the early group.
  
  
  CONCLUSIONS
  Our results outline that there is a linear relationship between the technical difficulties, expressed in term of operating time, and time intervals from the onset of symptoms to surgery. At the cut off time of 57 hrs of interval from the onset of symptoms to surgery, the linear regression coefficient that links the dependent variable OT to the independent variable ST changes increasing up to 1,92. Over 60 hrs from the onset of symptoms the pathological changes of the surgical target becomes more and more quickly a troublesome challenge to the surgeon, letting the laparoscopic cholecystectomy for AC more difficult and less safe than that performed early.
authors.affiliation: Emergency Department, Policlinico Umberto I University Hospital, Rome, Italy. marco.catani@uniroma1.it
authors.forename: Marco
authors.initials: M
authors.lastname: Catani
authors.forename: Ritanna
authors.initials: R
authors.lastname: De Milito
authors.forename: Francesco
authors.initials: F
authors.lastname: Romagnoli
authors.forename: Roberta
authors.initials: R
authors.lastname: Petroni
authors.forename: Giovanni
authors.initials: G
authors.lastname: Luciani
authors.forename: Teresa
authors.initials: T
authors.lastname: Ricciardulli
authors.forename: Claudio
authors.initials: C
authors.lastname: Modini
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017081:Cholecystectomy, Laparoscopic; D041881:Cholecystitis, Acute / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D055815:Young Adult