**3.2 Complicated gallstone disease**

Patients with gallstone disease affected by complications such as acute cholecystitis, cholangitis, biliary pancreatitis are recommended to undergo definitive surgical therapy.

In the treatment of acute calculous cholecystitis, it is important to correctly recognise indications for emergency surgery, which are complicated acute cholecystitis with gallbladder gangrene/necrosis, gallbladder perforation, and disease progression despite the medical therapy [6].

If the reasons for emergency surgery are not present, we have to stratify patients benefiting from early surgical intervention and those not profiting from surgery based on their physical status. According to Vollmer et al. [6], the use of the American Society of Anaesthesiologists (ASA) physical status classification is a good option because of its simplicity and ability to stratify patients into low-risk (ASA I-II) and high-risk (III, IV, V) groups with low-risk group patients generally being recommended early cholecystectomy. High-risk group patients are offered nonsurgical therapy, although in case of disease progression and ineffective initial therapy the surgical intervention may be reevaluated [6].

In the group of low-risk patients, the cholecystectomy should be performed as early as possible during the hospitalisation optimally in the first 72 h from the onset of symptoms as it is presumed that the local inflammation worsens with time [6]. Although current Tokyo guidelines as well as World Society of Emergency Surgery guidelines recommend early laparoscopic cholecystectomy also in patients after 72 h, as it is deemed safe because some patients present to hospital already after 72 h from the symptom onset [6]. Patients who have symptoms for longer than 10 days should be planned for delayed cholecystectomy after 6–8 weeks after resolution of the inflammation [6].

In the group of high-risk patients, the initial treatment starts with non-surgical approaches; however, when the disease progresses into gallbladder gangrene/ necrosis or perforation or does not respond either to medical therapy or to drainage intervention, the emergency cholecystectomy may be the only option despite the dangers of the surgery [6]. High-risk patients, who handle the acute phase, may be reassessed for delayed surgical intervention and in case of improved physical status may undergo surgery [6]. If the patient's physical status does not improve even after the resolution of the inflammation, these patients are eligible for nonsurgical treatment of gallstone disease [6].

### **3.3 Gallstone disease in pregnancy**

The higher frequency of gallstones in pregnancy compared to non-pregnant patients is based on the physiological functions of hormones released in higher quantities during the pregnancy [7]. Patients with uncomplicated symptomatic gallstone disease with recurrent biliary colic are indicated to undergo cholecystectomy [7]. Although in near term patients suffering from biliary colic, the surgery may by postpone until postpartum [7]. In such cases, it is recommended to perform surgery at least 6 weeks after delivery, but before 3 months after delivery prevent recurrent attacks of biliary colic [7]. Patients with complicated gallstone disease require complex treatment plans. For the patients with acute cholecystitis,

the surgery is a safe indication for the mother and foetus in every trimester [7]. However, increased preterm delivery has been associated with the cholecystectomy in the third trimester in several studies [7].

## **3.4 Surgical approach towards cholecystectomy**

Since the discovery of laparoscopy, this technique has been the mainstay in the surgical approach to gallstone disease regarding uncomplicated gallstone disease as well as complicated acute cholecystitis in low-risk and high-risk groups of patients as well as among pregnant patients unless there is an absolute anaesthetic contraindication [4, 6, 7]. The technical aspects of the laparoscopy in acute cholecystitis may be more demanding on the surgeon's skills; therefore, it is no shame to convert to open cholecystectomy when the surgeon is unable to visualise important anatomical structures with the emphasis on the patient's safety.
