Gallstones/Cholecystitis · Observe vs Surgery + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Symptoms/acute inflammation grade/high-risk
   Symptoms / acute inflammation grade / can the patient tolerate surgery? (Acute cholecystitis by TG18: Grade I (mild)/II (moderate, severe local)/III (severe, organ dysfunction).)
   • Asymptomatic gallstones → Asymptomatic → observe
   • Symptomatic (biliary colic) or acute cholecystitis Grade I/II, can tolerate surgery → Surgery · timing and approach
   • Acute cholecystitis Grade III / high-risk / cannot tolerate surgery → Grade III/high-risk → percutaneous drainage
2. [End] Asymptomatic → observe
   Asymptomatic gallstones → generally observe, no surgery. Exceptions for cholecystectomy: porcelain gallbladder, stones >3 cm, gallbladder polyp needing resection, hemolytic anemia, planned organ transplant/bariatric surgery.
3. [Decision] Surgery · timing and approach
   Cholecystectomy approach? (Timing: symptomatic → elective LC; acute cholecystitis Grade I/II tolerating surgery → early LC (ideally <72 h, within ≤7–10 days).)
   • Laparoscopic cholecystectomy LC (preferred) → Laparoscopic cholecystectomy (LC)
   • Open or conversion to open (unclear anatomy/bile duct injury risk/severe adhesions) → Open/conversion to open
4. [End] Grade III/high-risk → percutaneous drainage
   Acute cholecystitis Grade III (organ dysfunction)/high-risk/cannot tolerate surgery → percutaneous transhepatic gallbladder drainage (PTGBD) + antibiotics + support, with delayed LC once stable; or conservative.
5. [End] Laparoscopic cholecystectomy (LC)
   Laparoscopic cholecystectomy = gold standard; for a difficult gallbladder, subtotal cholecystectomy/fenestration (bail-out) to avoid bile duct injury (Critical View of Safety).
6. [End] Open/conversion to open
   Open or conversion to open — when Calot's triangle anatomy is unclear, with severe inflammation/adhesions, or suspected bile duct injury; safety first, intraoperative cholangiography/senior help as needed.

Source guidelines & references

• Tokyo Guidelines TG18 for acute cholecystitis + SAGES cholecystectomy guideline

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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