Background: Acute cholecystitis (AC) is a common surgical emergency, with laparoscopic cholecystectomy (LC) as the preferred treatment. However, difficult LC, characterized by prolonged operative time, bile spillage, or conversion to open surgery, poses significant challenges. The Tokyo Guidelines 2018 (TG18) provide a standardized framework for diagnosing and grading AC severity, but their role in predicting difficult LC and conversion remains under-explored. This study evaluates TG18’s accuracy in diagnosing AC and identifying preoperative predictors of difficult LC and conversion.

Methods: A prospective study of 46 patients with acute calculous cholecystitis was conducted from May 2023 to May 2025 at Rajindra Hospital, Patiala. Patients meeting TG18 diagnostic criteria underwent LC, with severity graded as mild (Grade 1), moderate (Grade 2), or severe (Grade 3). Preoperative factors (e.g., symptom duration >72 hours, gallbladder wall thickness ≥4–5 mm, elevated CRP/TLC) were correlated with intraoperative difficulties (operative time >60–120 minutes, bile spillage, or conversion) and bailout strategies (e.g., subtotal cholecystectomy, fundus-first technique).

Results: Of 46 patients (71.7% female, mean age 42.0 ± 14.0 years), 58.7% were predicted to have difficult LC, with 41.3% confirmed intraoperatively. Conversion to open surgery occurred in 8.7% (4/46), with Grade 3 showing the highest rate (25%), followed by Grade 1 (13.3%) and Grade 2 (3.7%). Hypotension (p=0.001) and oliguria (p=0.034) were significant predictors of conversion, while male gender (p=0.080), GB wall thickness (p=0.101), and fibrotic GB (p=0.116) showed trends toward intraoperative difficulty. No postoperative complications were observed.

Conclusion: TG18 is effective in diagnosing AC and stratifying severity, with moderate success in predicting difficult LC. Hypotension, oliguria, and higher TG grades are key predictors of conversion, while early LC reduces complications and hospital stay. Integrating TG18 with preoperative markers enhances surgical planning, minimizing intraoperative challenges and optimizing outcomes in AC management.