Acute cholecystitis (AC) is a common clinical emergency abdominal condition. With the increasing incidence of gallbladder stones and the aging of the population, the incidence of AC has tended to increase. AC is classified into acute calculous cholecystitis (ACC) and acute non-calculous cholecystitis (AAC) depending on the presence of gallbladder stones. Bile is altered compositionally, resulting in inflammation of the gallbladder wall, whereas AAC often occurs in patients of advanced age, after major trauma surgery, and in patients with severe diabetes mellitus, and its pathogenesis is mainly related to impaired blood flow to the gallbladder. The degree of histopathological changes of AAC is directly related to the cause, pathogenesis and time of onset. in the beginning stage of AC, the edema of the gallbladder wall is obvious and there is a certain degree of inflammatory exudation. at this time, although the pathological changes of the gallbladder are more obvious, there is no dense adhesion between the gallbladder and the surrounding organs and tissues. If surgical treatment is chosen in the early stage of AC, the difficulty of important operations such as tissue separation and identification during surgery is not significantly increased compared with that in non-acute inflammation, on the contrary, it also seems to be relatively easy to separate due to tissue edema and vascular embolism. If the cause of AC is not removed in time and the inflammation persists for a longer period of time, further pathological changes in the gallbladder may lead to suppuration of the gallbladder, gangrene of the gallbladder wall, and then perforation, resulting in limited or diffuse peritonitis. The traditional treatment is open cholecystectomy (OC). Since Eric Muhe performed the first laparoscopic cholecystectomy (LC) in 1985, the concept of minimally invasive surgical treatment has taken root, and with the flourishing of lumpectomy and various imaging-mediated treatment techniques, LC has gradually become the surgical procedure of choice for most gallbladder disorders, but AC has been considered a contraindication to LC for a long time. However, AC was considered a contraindication to LC for a long time. In the last decade or so, with the improvement of technology and accumulation of experience, the indications for LC have been steadily expanded, and traditional contraindications to LC, such as acute cholecystitis, history of upper abdominal surgery, and atrophic cholecystitis, are being transformed into indications for LC one by one. In addition, single-port LC and even cholecystectomy via the natural cavity have been successively developed to reduce or hide the surgical scar. Obviously, the treatment concept of AC has undergone a significant change from the single open surgery in the past to a comprehensive treatment model with minimally invasive treatment as the mainstay and the combined application of various means. The main points include the following: The traditional treatment principle of AC in the context of minimally invasive surgery concept has obvious shortcomings The traditional treatment principle of AC is based on conservative treatment methods such as fasting, antispasmodic and anti-inflammatory. In the early stage of onset (usually considered to be within 72 h of onset), if the disease is severe and the success rate of conservative treatment is low, emergency OC or cholecystostomy may be considered; if the disease is mild, conservative treatment is preferred, and if the disease worsens during the course of conservative treatment, emergency surgery is performed, and the surgical approach is either OC or cholecystostomy depending on the disease and technique. However, the traditional treatment principle of AC has its inherent disadvantages. First, there is a risk of delaying the timing of emergency LC, forcing OC if conservative treatment fails, and the risks of performing emergency OC when the condition is far from being controlled or even significantly aggravated are greater – more postoperative complications, higher incisional infection rate, longer hospital stay, etc.; second, even if conservative treatment is effective, some patients will recur while waiting for the elective AC will recur while waiting for the timing of surgery, and can even be complicated by serious complications such as common bile duct stones and biliary pancreatitis. Repeated multiple treatments increase the pain of patients and waste medical resources. In addition, after successful conservative treatment of ACC, patients may refuse elective surgical treatment due to the existence of a fluke mentality, which may lay hidden dangers for future complications such as common bile duct stones, biliary pancreatitis and gallbladder cancer. Emergency LC is a safe and effective means of treating AC and needs to be further popularized At the early stage of laparoscopic technology, AC was regarded as a contraindication to LC. With the accumulation of experience, improvement of technology, and upgrading of equipment, the indications for LC have been gradually relaxed, and AC has become a routine indication for LC in most medical centers. Several randomized controlled studies have demonstrated that there is no statistically significant difference in complication rates between emergency LC for AC and elective LC for chronic cholecystitis, and that the length of stay in hospital, the number of hospitalizations, and the cost of care are reduced in emergency LC with the same therapeutic effect. Therefore, emergency LC has become the best treatment option for AC. Currently, there are different perceptions on the timing of surgery for emergency LC. Some scholars believe that the best time for emergency LC is within 48 h, 72 h, or 96 h after the onset of symptoms, and some even recommend emergency LC within 7 d after the onset of symptoms, and the reported rate of laparoscopic surgery for AC and the complication rate vary greatly depending on the timing of surgery. However, most authors believe that the best time for emergency LC is within 72 h of the onset of AC. The Tokyo guidelines suggest that LC should be chosen with great caution when the onset of AC is longer than 72 h, the gallbladder wall thickness is >8 mm, and the white blood cell count is >18×109/L. Although emergency LC has become the best option for the treatment of AC, in practice, emergency LC for AC has not been commonly performed. According to the UK health authorities, only 11% of the 48,064 patients treated with LC in 2004 received emergency LC, and more patients with AC received conservative treatment followed by elective LC, resulting in longer waiting times for surgery, more hospitalizations, and higher medical costs [5]. The reasons why emergency LC treatment for AC has not been widely carried out include: primary hospitals lack the technology and experience in emergency lumpectomy; large hospitals have not yet established a green channel for emergency LC treatment, and junior doctors are often the first physicians for AC patients, who lack the experience in judging the timing of surgery and the ability to organize emergency lumpectomy; both doctors and patients have not fully accepted the concept of emergency LC treatment, and are not confident in the Both doctors and patients have not fully accepted the concept of emergency LC treatment and are not confident in the safety of emergency LC. It can be seen that changing the treatment concept and systematically mastering laparoscopic techniques are important ways to popularize emergency LC. Compared with elective LC, emergency LC for AC has greater difficulty and greater risk, and the operator must have skillful laparoscopic surgical techniques and master the technical points for AC (1) The gallbladder is often wrapped by large omental, gastric, and intestinal duct adhesions, and when separating the adhesions, the gallbladder is separated along the bottom of the gallbladder tightly against the wall to the abdomen of the gallbladder pot. (2) If the gallbladder is under high tension and clamping is difficult, the bottom of the gallbladder can be punctured to decompress it. (3) If the stone is embedded in the neck of the gallbladder, the stone can be squeezed into the gallbladder with separating forceps or flushers, thus leaving a larger gap for freeing the cystic duct; if the stone is tightly embedded and cannot be pushed, it can be cut along the long axis of the cystic duct and squeezed out. (4) When dissecting the gallbladder triangle, the gallbladder should be separated along the lower edge of the gallbladder jugular and the cystic duct toward the common bile duct, and bluntly peeled off with a flushing device and combined with electric hook or separating forceps to reduce blood leakage from the trauma. (5) When separating the fatty and fibrous tissues in the triangle of gallbladder with electric hook, we should remember to hook up the tissues several times in small amount, and in case of obvious tension, we should identify whether it is the gallbladder artery, free it first and then clamp it, and do not electrocoagulate it to prevent postoperative tissue necrosis and hemorrhage. (6) If the cervical junction of the gallbladder is really difficult to separate, laparoscopic subtotal cholecystectomy (LSC) can be performed. Effective measures to reduce the risk of emergency LC surgery and the rate of open abdomen The surgical difficulty and risk are greater when treating AC in emergency LC, and the rate of open abdomen is higher. The incidence of wound infection was 14.0%, the incidence of bile leak was 14.0%, and the length of hospital stay was significantly prolonged after the intermediate open abdomen surgery. Although the intermediate open abdomen is the most common measure to reduce and avoid risks during laparoscopic surgery, it is, after all, a reluctant and unacceptable option for both doctors and patients. In fact, open laparotomy does not provide a clearer view and anatomy than lumpectomy, but only allows the surgeon to change to a more familiar surgical approach without really getting rid of the underlying causes of increased surgical risk DD adhesions and anatomical difficulties. LSC, as the name implies, is a procedure to preserve part of the gallbladder tissue in situ without complete removal of the gallbladder under certain special circumstances, such as deep gallbladder bed, cirrhotic background, and poor anatomy of the gallbladder triangle. LSC Ⅰ: LSC that preserves the wall of the gallbladder on the gallbladder bed, which is suitable for those who have difficulty in exposing the gallbladder bed and have the possibility of hemorrhage; LSC Ⅱ: LSC that preserves part of the gallbladder pot belly, which is suitable for those who have difficulty in dissecting the gallbladder triangle; LSC Ⅲ: it is a combination of the first two procedures, which preserves both part of the gallbladder pot belly and the wall of the gallbladder on the gallbladder bed. , the search and ligation of the cystic duct is not forced due to the difficulty in identifying the anatomical position of the gallbladder triangle. It is not necessary to intentionally dissect the gallbladder artery, and if there is bleeding, it can be clamped closed. The following points should be noted when performing LSC: (1) Emphasize the treatment of residual gallbladder mucosa to remove its secretory function. Electrocoagulation cautery is the most effective method to remove the residual mucosa. (3) Routinely place a drainage tube at the small omental orifice. (4) Regarding accidental gallbladder cancer, the incidence is reported in the literature as 0.2% to 0.8%. If the gallbladder wall of gallbladder cancer is incised, it is prone to residual cancer and abdominal dissemination. Preoperative abdominal ultrasound, CT and tumor markers should be routinely examined. If gallbladder cancer is suspected preoperatively, LSC should not be performed. The advantages of the procedure are as follows: it expands the indications for laparoscopic surgery, avoids intermediate open abdomen, reduces trauma, and has fast postoperative recovery; it is safe and effective, and can reduce the risk of biliary tract injury; it avoids partial laparoscopic cholecystostomy, thus avoiding secondary surgery; it is less difficult and operable, and is easy to be mastered by junior doctors and doctors in primary hospitals. Therefore, LSC is safer and more effective than LC when encountering complex AC, and there is no need to pursue “perfection” on the operating table, and LSC can avoid intermediate openings, reduce trauma and risks when performed at the right time. Percutaneous transhepatic gallbladder drainage (PTGBD) is suitable for AC patients who cannot tolerate surgery. Elderly patients with AC who have other organ disorders, or those with severe disease, who cannot tolerate anesthesia and surgical treatment, have a mortality rate of 14.0% to 30.0%. Although the incidence of AAC accounts for only 2.0% to 15.0% of AC, it has a complex etiology, rapid onset and progression, and is prone to serious complications such as gallbladder gangrene and perforation, and has a high mortality rate. As a simple, effective, minimally invasive and economical gallbladder or/and biliary drainage procedure with definite drainage effect, it is an effective emergency measure for acute, critical and severe biliary tract disorders. In patients with AC who have difficulty tolerating surgery, PTGBD can avoid the risk and trauma of emergency LC and OC, and plays an important role as a bridge to elective cholecystectomy after acute attack control; it can be used as a palliative treatment for AC in pregnancy and as a preparation for postpartum cholecystectomy. In patients with AAC, if the primary attack is satisfactorily controlled, AAC may not recur and cholecystectomy is not necessary; in some patients with advanced age and high-risk ACC, it is sufficient to achieve the purpose of life saving, and the condition can enter the observation period after stabilization. Data show that the failure rate of ultrasound-guided PTGBD is 0% to 6.0%, the drainage tube prolapse rate is 5.0% to 18.0%, and the complication rate associated with the operation is 4.0% to 18.0%, including colonic injury perforation. It is clear that PTGBD, although a simple operation, should be performed with adequate preparation and caution. PTGBD should be contraindicated or used with caution in the presence of the following conditions: patients with a significant bleeding tendency; patients in poor general condition with peritoneal effusion, especially in the presence of prehepatic effusion; patients with significant atrophy of the gallbladder; patients whose whole gallbladder is not visible on ultrasonography due to obesity and pneumoperitoneum; patients with significant gallbladder gangrene, near perforation or already perforated. The high incidence of drainage tube prolapse should be taken seriously and actively prevented. If no bile is drained from the drainage duct, the first step is to determine whether the drainage duct is obstructed or not, and saline flushing can be tried. Once the drainage tube is dislodged, if it is a non-transhepatic route, it is easy to develop biliary peritonitis, and it is best to perform PTGBD again within 6 hours, or surgical treatment; if it is a transhepatic route, it is less likely to have bile leakage, and the time limit for definitive treatment can be extended to 24 hours. . With the increasing proportion of elderly population, the incidence of gallbladder stones and AC in the elderly is also increasing year by year. Geriatric AC has become a common and difficult clinical problem. Elderly patients with AC usually have the following clinical characteristics: (1) many physical comorbidities, poor condition, poor tolerance to anesthesia and surgery, and many postoperative complications; (2) poor body resistance, inflammation is not easily controlled, and gallbladder gangrene and perforation are prone to occur; (3) insensitivity to disease response and easy to delay diagnosis; (4) high rate of combined common bile duct stones and peri-pot belly s chamber [20] and complex condition; (5 ) longer duration of gallbladder stones and high rate of gallbladder cancer combination; (6) a larger proportion of AAC in elderly AC compared with the middle-aged and young patient group; (7) heavy influence of traditional concepts, inclination to conservative treatment, and low desire for active surgical treatment. Due to the above characteristics of elderly AC patients, the melody of traditional treatment principles for elderly AC is passive conservative treatment – strong fear of physicians and reluctance of patients and families to surgical treatment. But still, due to the above-mentioned characteristics of elderly AC patients, conservative treatment does not work for a significant proportion of patients and has a certain failure rate; after the failure of conservative treatment, the patient’s systemic condition worsens and the timing of surgery is delayed. Even if conservative treatment is effective, some patients may still have recurrent attacks, which seriously affects the quality of life of patients. riall et al. analyzed and summarized the treatment and prognosis of 29,818 elderly AC patients over 66 years old from 1996 to 2005, and showed that 38% of patients in the conservative treatment group had recurrent AC within 2 years, and their 2-year survival rate was significantly lower than that of the emergency surgery group. With the accumulation of experience in laparoscopic surgery and the improvement of the treatment level of perioperative management ability, emergency LC treatment for elderly AC has proven to be a safe and effective treatment option, and surgeons are increasingly inclined to more aggressive surgical treatment: emergency LC should be pursued when the systemic condition allows and the physical condition can tolerate the surgical and anesthetic trauma; when the intraoperative peribiliary inflammation is heavy and the gallbladder triangle dissection is difficult LSC or cholecystostomy should be considered. In conclusion, the traditional treatment principles of AC have many drawbacks. In the context of minimally invasive surgery, the treatment concept of AC has undergone a significant change. Emergency LC has become the treatment of choice for AC (including elderly AC); if intraoperative gallbladder inflammation is heavy and dissection is difficult, LSC can be chosen in due course to avoid intermediate open abdomen and reduce surgical risk. In critically ill patients who have difficulty tolerating surgical and anesthetic strikes, PTGBD should be chosen and can be used as a bridge to elective cholecystectomy after acute attack control.