Abstract
Objective
To investigate the perioperative outcomes and safety of different completion statuses of laparoscopic cholecystectomy (LC) in elderly patients, providing evidence for surgical risk assessment and perioperative management.
Methods
A single-center retrospective study was conducted. Clinical data of elderly patients undergoing LC from January 2023 to December 2024 were collected. Patients were categorized into a difficult laparoscopic cholecystectomy (DLC) group or a successfully completed laparoscopic cholecystectomy (SCLC) group based on intraoperative completion status and technical difficulty. Data on operative parameters, postoperative recovery, postoperative complications, and inflammatory markers [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP)] were analyzed. Independent risk factors for complications were identified via multivariate logistic regression.
Results
The SCLC group had significantly shorter operative time, less intraoperative blood loss, and attenuated postoperative rises in TNF-α, IL-6, and CRP compared to the DLC group (all P < 0.05). Recovery was faster in the SCLC group, evidenced by earlier time to first flatus and oral intake, shorter length of hospital stay, and lower Visual Analog Scale (VAS) pain scores (all P < 0.05). The overall complication rate was lower in the LC group (7.50% vs. 30.00%, P < 0.05). American Society of Anesthesiologists (ASA) class III and ≥ 2 comorbidities were independent risk factors for complications (P < 0.05).
Conclusion
LC is generally safe and feasible for elderly patients. However, completion status and intraoperative difficulty are closely associated with perioperative outcomes. Patients with lower surgical difficulty and successful completion experience faster recovery and lower complication rates.
Keywords: Elderly patients, Laparoscopic cholecystectomy, Completion status, Difficult laparoscopic cholecystectomy, Postoperative complications
Introduction
Gallstones are among the most common hepatobiliary disorders in middle-aged and elderly populations, with pathogenesis closely associated with bile component imbalance, cholesterol metabolism disorders, and impaired gallbladder motility [1]. With population aging, the incidence of gallstone-related diseases continues to increase, making surgical management in elderly patients a growing clinical concern. Elderly patients often experience declined physiological function, including reduced vascular elasticity and weakened immune responses. They frequently present with comorbidities such as hypertension, diabetes, and coronary heart disease, which complicate clinical management [2, 3].
Laparoscopic cholecystectomy (LC) has become the preferred minimally invasive approach for gallbladder diseases, offering advantages such as minimal invasiveness, reduced intraoperative bleeding, faster recovery, and lower complication rates [4, 5]. However, in elderly patients, chronic inflammatory changes, dense adhesions in Calot’s triangle, and anatomical variations may significantly increase operative difficulty, thereby affecting the safety and feasibility of laparoscopic procedures [6]. Previous studies have shown that increased operative difficulty is associated with longer operative time, higher conversion rates, and increased postoperative complications [7], yet most existing evidence is derived from general populations, and limited data specifically focus on elderly patients(≥ 70 years).
Given this background, the present study aimed to evaluate the impact of operative difficulty and laparoscopic completion status on intraoperative parameters, postoperative recovery, inflammatory responses, and complication rates in elderly patients undergoing LC. It will further explore independent risk factors for postoperative complications. The study may provide an evidence-based foundation for surgical risk assessment, procedure selection, and individualized perioperative management for elderly patients with gallbladder disease. It also offer references for optimizing surgical strategies to enhance postoperative safety and recovery quality in this population.
Subjects and methods
Study subjects
This single-center retrospective study collected clinical data from elderly patients who underwent LC in the Department of Hepatobiliary Surgery at our hospital between January 2023 and December 2024. A total of 160 eligible elderly patients were ultimately included. The study adhered to the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Xinyu People’s Hospital ( Approval No. RMYY20251225002), with a waiver for informed consent granted.
Inclusion criteria were: ① Age ≥ 70 years; ② Preoperative diagnosis of benign gallbladder disease (including gallstones with chronic cholecystitis, gallbladder polyps, or gallbladder adenomyomatosis) confirmed by abdominal ultrasound, computed tomography, and/or magnetic resonance imaging; ③ Underwent LC; ④ Complete clinical data and available postoperative follow-up information.
Exclusion criteria included: ① Concomitant severe gallbladder pathologies such as acute severe cholangitis, gallbladder perforation, or gallbladder carcinoma; ② Presence of surgical contraindications including severe cardiac insufficiency, hepatic or renal failure, or coagulation disorders; ③ Previous history of upper abdominal surgery; ④ Incomplete clinical data.
Grouping method
Patients were classified according to intraoperative technical difficulty and the surgical strategy ultimately adopted. Specifically, procedures completed using a standard laparoscopic technique without the need for conversion or alternative approaches were classified as the successfully completed laparoscopic cholecystectomy (SCLC) group. In contrast, cases in which significant intraoperative difficulty was encountered—such as severe inflammation, dense adhesions, or unclear anatomy—requiring modification of the standard approach, including conversion to open surgery, subtotal cholecystectomy, or the use of bailout techniques (e.g., fundus-first approach), were classified as the difficult laparoscopic cholecystectomy (DLC) group. Final treatment approach refers to the actual surgical strategy adopted intraoperatively based on operative findings and the surgeon’s judgment. According to these classification criteria, patients were divided into the DLC group (n = 80) and the SCLC group (n = 80). The equal distribution between groups was not predetermined or artificially matched, but rather reflected the actual classification of eligible patients during the study period according to operative difficulty and surgical completion status.
Methods
Patients underwent LC under general anesthesia with endotracheal intubation. The surgical protocol was as follows: ① Preoperative preparation: The patient was placed in the supine position. ② Pneumoperitoneum establishment: Approximately a 10-mm incision was made at the umbilicus for the insertion of a Veress needle. Carbon dioxide was insufflated to maintain an intra-abdominal pressure of 12–14 mmHg; ③ Trocar placement: A 10-mm trocar was inserted at the umbilicus as the observation port. A 5-mm and a 10-mm trocar were placed subxiphoid and below the right costal margin, respectively, as operating ports; ④ Surgical procedure: The anatomy of Calot’s triangle was exposed to identify the cystic duct and cystic artery and their relationship to the common bile duct. The cystic artery and cystic duct were clipped with titanium clips and divided. The gallbladder was dissected from its bed and completely removed, with extraction of the specimen through the umbilical port. After confirming no active bleeding or bile leakage, the pneumoperitoneum was released and the incisions were sutured; ⑤ Postoperative management: Routine wound care was provided, with antibiotic therapy administered when necessary. A procedure was classified as DLC when intraoperative findings (such as severe inflammation, dense adhesions, or unclear anatomy) resulted in technical difficulty requiring conversion to open surgery or the use of bailout procedures.
All procedures were performed by surgeons from the same hepatobiliary surgical team. The surgeons had substantial experience in laparoscopic cholecystectomy and had completed standardized training in minimally invasive surgery. All procedures were conducted according to a unified surgical protocol.
Outcomes
Primary outcomes
① Intraoperative indicators: Operative time, intraoperative blood loss, intraoperative heart rate (HR), blood pressure, and number of cases with delayed anesthesia recovery were recorded for both groups. ② Postoperative complications: The incidence of complications was observed and recorded, including intra-abdominal hemorrhage, postoperative bile leakage, surgical site infection (SSI), pulmonary infection, intra-abdominal fluid collection, and extrahepatic bile duct injury. A higher incidence indicated poorer clinical outcomes.
Secondary outcomes
① Inflammatory factors: Fasting venous blood (5 mL) was collected preoperatively and on postoperative day 1. Serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and C-reactive protein (CRP) were measured using enzyme-linked immunosorbent assay after centrifugation. ② Postoperative recovery indicators: Time to first flatus, time to oral intake, length of hospital stay (LOS), and pain score at 24 h postoperatively were recorded. Pain intensity was assessed using the Visual Analog Scale (VAS) [8] (score range 0–10, with higher scores indicating more severe pain).
Statistical analysis
Statistical analysis was performed using SPSS software (version 26.0). Continuous data were presented as mean ± standard deviation (x̄ ± s) and compared between groups using the independent samples t-test when confirming to a normal distribution. Normality was assessed using the Shapiro-Wilk test. Categorical data were presented as n (%) and compared using the chi-square (χ²) test. Variables with P < 0.05 in univariate analysis were further included in a multivariate logistic regression analysis to identify independent risk factors for postoperative complications following LC in elderly patients. Due to the small number of complication events (n = 6), Firth’s penalized logistic regression model was employed to reduce small-sample bias and improve the stability of parameter estimates.
Results
Patient general information
A total of 160 elderly patients (aged ≥ 70 years) were included in this study. According to classification criteria, patients were divided into the DLC group (n = 80) and the SCLC group (n = 80). There were no significant differences in baseline characteristics between the two groups (P > 0.05). Baseline demographic and clinical characteristics of the two groups are summarized in Table 1.
Table 1.
Baseline characteristics of patients in the two groups
| Parameters | DLC group (n = 80) | SCLC group (n = 80) | t/X2 | P |
|---|---|---|---|---|
| Gender (n, %) | 0.287 | 0.592 | ||
| Male | 48 (60.0) | 45 (56.25) | ||
| Female | 32 (40.0) | 35 (43.75) | ||
| Age (years) | 78.31 ± 4.19 | 77.54 ± 4.22 | 0.986 | 0.326 |
| BMI (kg/m²) | 23.52 ± 2.17 | 23.28 ± 2.31 | 0.542 | 0.589 |
| ASA classification (n, %) | 0.654 | 0.721 | ||
| Class Ⅰ | 12 (15.0) | 14 (17.5) | ||
| Class Ⅱ | 45 (56.25) | 43 (53.75) | ||
| Class Ⅲ | 23 (28.75) | 23 (28.75) | ||
| Comorbidities (n, %) | ||||
| Hypertension | 38 (47.5) | 36 (45.0) | 0.128 | 0.721 |
| Diabetes mellitus | 25 (31.25) | 27 (33.75) | 0.156 | 0.693 |
| Coronary heart disease | 19 (23.75) | 21 (26.25) | 0.172 | 0.678 |
| Duration of gallbladder disease (years) | 4.25 ± 1.83 | 4.51 ± 1.96 | 0.763 | 0.447 |
DLC Difficult laparoscopic cholecystectomy, SCLC Successfully completed laparoscopic cholecystectomy, BMI Body mass index, ASA American Society of Anesthesiologists
Comparison of operative indicators
Operative time and intraoperative blood loss were significantly lower in the SCLC group compared to the DLC group (P < 0.05). No significant differences were found between the two groups regarding intraoperative HR, blood pressure, or the number of cases with delayed anesthesia recovery (P > 0.05) (Table 2).
Table 2.
Comparison of operative indicators between groups
| Variable | DLC group (n = 80) | SCLC group (n = 80) | t/χ² | P |
|---|---|---|---|---|
| Operative time (min) | 75.32 ± 12.45 | 52.18 ± 10.76 | 11.893 | < 0.001 |
| Intraoperative blood loss (mL) | 82.65 ± 20.31 | 35.42 ± 15.68 | 16.745 | < 0.001 |
| Intraoperative HR (beats/min) | 82.56 ± 9.34 | 80.72 ± 8.96 | 1.125 | 0.262 |
| Intraoperative SBP (mmHg) | 135.28 ± 12.45 | 132.65 ± 11.87 | 1.236 | 0.218 |
| Intraoperative DBP (mmHg) | 78.56 ± 8.21 | 76.93 ± 7.95 | 1.058 | 0.292 |
| Delayed anesthesia recovery | 5 (6.25%) | 4 (5.00%) | 0.128 | 0.721 |
Continuous variables are presented as mean ± standard deviation (x̄ ± s), and categorical variables are expressed as number (percentage)
DLC Difficult laparoscopic cholecystectomy, SCLC Successfully completed laparoscopic cholecystectomy, HR Heart rate, SBP Systolic blood pressure, DBP Diastolic blood pressure
Comparison of inflammatory factors
Preoperatively, there were no significant differences in serum levels of TNF-α, IL-6, or CRP between the two groups (P > 0.05). Postoperatively, levels of these markers increased significantly in both groups compared to preoperative levels (all P < 0.05). However, the postoperative increase was significantly smaller in the SCLC group than in the DLC group (P < 0.05) (Table 3).
Table 3.
Comparison of inflammatory factors between groups
| Variable | Time point | DLC group (n = 80) | SCLC group (n = 80) | t | P |
|---|---|---|---|---|---|
| TNF-α (ng/L) | Preoperative | 12.35 ± 3.12 | 12.18 ± 3.05 | 0.326 | 0.744 |
| Postoperative | 38.67 ± 6.45*** | 25.43 ± 5.72*** | 12.587 | < 0.001 | |
| IL-6 (ng/L) | Preoperative | 15.42 ± 4.28 | 15.16 ± 4.15 | 0.389 | 0.697 |
| Postoperative | 52.31 ± 8.76*** | 32.65 ± 7.43*** | 14.215 | < 0.001 | |
| CRP (mg/L) | Preoperative | 8.25 ± 2.36 | 8.12 ± 2.28 | 0.318 | 0.751 |
| Postoperative | 45.78 ± 9.21*** | 28.35 ± 8.64*** | 11.963 | < 0.001 |
Continuous variables are presented as mean ± standard deviation (x̄ ± s)
DLC Difficult laparoscopic cholecystectomy, SCLC Successfully completed laparoscopic cholecystectomy, TNF-α Tumor necrosis factor-alpha, IL-6 Interleukin-6, CRP C-reactive protein
***P < 0.001 vs. preoperative level within the same group
Comparison of postoperative recovery indicators
Time to first flatus and time to oral intake were significantly earlier, LOS was significantly shorter, and the VAS pain score was significantly lower in the SCLC group compared to the DLC group (all P < 0.05) (Table 4).
Table 4.
Comparison of postoperative recovery indicators between groups
| Variable | DLC group (n = 80) | SCLC group (n = 80) | t | P |
|---|---|---|---|---|
| Time to first flatus (h) | 36.52 ± 8.74 | 22.18 ± 7.56 | 10.325 | < 0.001 |
| Time to oral intake (h) | 48.35 ± 10.26 | 24.45 ± 8.93 | 15.715 | < 0.001 |
| Length of hospital stay (d) | 10.56 ± 2.31 | 5.23 ± 1.87 | 16.040 | < 0.001 |
| VAS score (24 h) | 6.82 ± 1.54 | 3.56 ± 1.28 | 15.893 | < 0.001 |
Continuous variables are presented as mean ± standard deviation (x̄ ± s)
DLC Difficult laparoscopic cholecystectomy, SCLC Successfully completed laparoscopic cholecystectomy, LOS Length of hospital stay, VAS Visual Analog Scale
Comparison of complication rates
The overall complication rate was significantly lower in the SCLC group than in the DLC group (P < 0.05) (Table 5).
Table 5.
Comparison of complication rates between groups
| Variable | DLC group (n = 80) | SCLC group (n = 80) | Test | P |
|---|---|---|---|---|
| Intra-abdominal hemorrhage | 1 (1.25%) | 0 (0.00%) | Fisher’s exact | 1.000 |
| Postoperative bile leakage | 2 (2.50%) | 1 (1.25%) | Fisher’s exact | 0.497 |
| Surgical site infection | 8 (10.00%) | 2 (2.50%) | Fisher’s exact | 0.210 |
| Pulmonary infection | 6 (7.50%) | 1 (1.25%) | Fisher’s exact | 0.117 |
| Intra-abdominal fluid collection | 4 (5.00%) | 1 (1.25%) | Fisher’s exact | 0.367 |
| Extrahepatic bile duct injury | 1 (1.25%) | 0 (0.00%) | Fisher’s exact | 1.000 |
| Total complication rate | 22 (27.50%) | 5 (6.25%) | χ²=12.88 | < 0.001 |
Categorical variables are presented as number (percentage)
DLC Difficult laparoscopic cholecystectomy, SCLC Successfully completed laparoscopic cholecystectomy, SSI Surgical site infection
Analysis of factors influencing postoperative complications in LC patients
Univariate analysis showed that American Society of Anesthesiologists (ASA) classification and the number of pre-existing comorbidities were significantly different between the complication and non-complication subgroups (P < 0.05) (Table 6). Variables with P < 0.05 in the univariate analysis were entered into the multivariate logistic regression model. Binary assignment was applied as follows: ASA classification (Class III = 1, Class I–II = 0) and number of comorbidities (≥ 2 = 1, < 2 = 0). Multivariate logistic regression analysis confirmed that ASA classification and the number of pre-existing comorbidities were independent risk factors for postoperative complications in elderly patients undergoing cholecystectomy (P < 0.05) (Table 7).
Table 6.
Univariate analysis of factors influencing postoperative complications in LC patients
| Factor | Complication group (n = 6) | Non-complication group (n = 74) | Univariate analysis | |
|---|---|---|---|---|
| χ²/t | P | |||
| Age | 2.158 | 0.142 | ||
| 70–79 years | 4 (66.67%) | 58 (78.38%) | ||
| ≥ 80 years | 2 (33.33%) | 16 (21.62%) | ||
| BMI | 0.896 | 0.344 | ||
| < 24 kg/m² | 3 (50.00%) | 39 (52.70%) | ||
| ≥ 24 kg/m² | 3 (50.00%) | 35 (47.30%) | ||
| ASA classification | 6.325 | 0.012 | ||
| Class Ⅰ~Ⅱ | 2 (33.33%) | 62 (83.78%) | ||
| Class Ⅲ | 4 (66.67%) | 12 (16.22%) | ||
| Number of comorbidities | 7.841 | 0.005 | ||
| < 2 | 1 (16.67%) | 59 (79.73%) | ||
| ≥ 2 | 5 (83.33%) | 15 (20.27%) | ||
| Duration of gallbladder disease | 1.024 | 0.311 | ||
| < 5 years | 3 (50.00%) | 41 (55.41%) | ||
| ≥ 5 years | 3 (50.00%) | 33 (44.59%) | ||
LC Laparoscopic cholecystectomy, BMI Body mass index, ASA American Society of Anesthesiologists
Table 7.
Multivariate logistic regression analysis
| Factor | β | SE | P | Wald χ2 | OR | 95% CI |
|---|---|---|---|---|---|---|
| ASA classification | 1.135 | 0.386 | 0.009 | 6.638 | 3.108 | 1.326 ~ 7.289 |
| Number of comorbidities | 1.269 | 0.398 | 0.003 | 8.447 | 3.562 | 1.534 ~ 8.276 |
ASA American Society of Anesthesiologists, SE Standard error, OR Odds ratio, CI Confidence interval
Discussion
Surgical management of gallbladder disease in elderly patients presents significant challenges, primarily due to age-related physiological decline and the frequent accumulation of multiple comorbidities. While LC is the preferred minimally invasive approach owing to its benefits of reduced trauma, less bleeding, and quicker recovery, factors including chronic local inflammation, adhesions in Calot’s triangle, and complex anatomy in elderly patients can increase operative difficulty. This may lead to greater blood loss, prolonged surgery, and potentially affect perioperative outcomes [9]. Therefore, analyzing the relationship between LC completion status and postoperative recovery/complications in this population holds substantial clinical significance.
Our findings showed that the SCLC group had significantly shorter operative times and less intraoperative blood loss than the DLC group. This suggests that successful completion substantially reduces intraoperative trauma and bleeding risk, consistent with prior research [10, 11]. When the cystic triangle anatomy is complex, or local fibrosis and inflammation are pronounced, operative difficulty rises, potentially prolonging surgery and increasing intraoperative complications. Our study implies that preoperative imaging assessment and surgeon expertise play crucial roles in ensuring successful procedure completion.
TNF-α, IL-6, and CRP in this study were used to characterize postoperative inflammatory response and intergroup differences in surgical stress, rather than to evaluate their independent predictive value for clinical outcomes. Changes in postoperative inflammatory markers further corroborate the impact of completion status on the body’s stress response. The SCLC group exhibited a markedly smaller increase in TNF-α, IL-6, and CRP levels postoperatively compared to the DLC group. This indicates that lesser surgical trauma can effectively attenuate the systemic inflammatory response [12, 13]. This is particularly important for elderly patients, as an exaggerated inflammatory response may elevate complication risks and prolong recovery.
Regarding postoperative recovery, the SCLC group showed superior outcomes for time to first flatus, time to oral intake, and length of hospital stay, along with significantly lower VAS pain scores. These findings align with studies by Antoniou et al. [14] and Kivivuori et al. [15], indicating that successful surgical completion accelerates gastrointestinal function recovery, shortens hospitalization, and improves postoperative comfort.
Complication analysis revealed a significantly lower overall rate in the SCLC group. Both univariate and multivariate logistic regression analyses identified ASA classification and number of comorbidities as independent risk factors for postoperative complications. This underscores the need for comprehensive preoperative assessment of overall health status in elderly LC candidates. Individualized surgical and perioperative management plans should be formulated for high-risk patients to enhance the likelihood of successful completion and reduce complication rates.
However, this study still has several limitations. First, its single-center retrospective design and relatively limited sample size may introduce selection and information bias, and potential unmeasured confounding variables that could not be fully adjusted for in the analysis. Second, the definition of difficult laparoscopic cholecystectomy (DLC) was based on intraoperative judgment rather than standardized scoring systems, which may introduce a degree of subjectivity. Third, long-term quality of life follow-up was not conducted. Fourth, stratified analysis based on different comorbidity types or complex surgical scenarios was not performed. Fifth, although all procedures were performed by experienced surgeons using standardized techniques, operator-related variability cannot be completely excluded. In addition, the low number of complication events (n = 6) may limit the statistical power of the multivariate analysis and increase the risk of overfitting, which could potentially lead to an overestimation of effect estimates; thus, these findings should be interpreted cautiously. Future multicenter, prospective studies incorporating long-term follow-up are warranted to further validate the safety and efficacy of LC in the elderly and to explore optimized strategies for high-risk patients.
In conclusion, the completion status of LC is closely associated with perioperative outcomes in elderly patients. Successfully completed procedures effectively shorten operative time, reduce intraoperative bleeding, attenuate inflammatory responses, accelerate postoperative recovery, and lower complication rates. With strict adherence to indications, thorough preoperative evaluation, and adequate surgical expertise, laparoscopic cholecystectomy should be considered the preferred minimally invasive option for gallbladder disease in elderly patients.
Acknowledgements
Not applicable.
Authors’ contributions
Yujun Zhang: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Visualization; Writing–original draft. Xingxing Jiang: Conceptualization; Methodology; Supervision; Project administration; Resources; Validation; Writing–review & editing. All authors have read and approved the final version of the manuscript.
Funding
None.
Data availability
The data used and/or analyzed during the current study are available from the corresponding author.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethics Committee of Xinyu People’s Hospital (Approval No. RMYY20251225002).
Given the retrospective design of the study and the use of anonymized patient data, the requirement for informed consent was waived by the Ethics Committee in accordance with institutional regulations and relevant national guidelines governing retrospective studies using de-identified clinical data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and/or analyzed during the current study are available from the corresponding author.