Early Versus Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: A Systematic Review

Acute calculous cholecystitis is a common emergency surgical condition, and the optimal timing of laparoscopic cholecystectomy (LC) remains controversial. Previous meta-analyses have not consistently distinguished evidence from randomized controlled trials (RCTs) and observational studies or separated postoperative complications from composite strategy-level morbidity. We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines by searching PubMed, the Cochrane Library, Scopus, and Web of Science from inception through June 2026. Dichotomous outcomes from RCTs were pooled using the DerSimonian-Laird random-effects model, while observational studies were synthesized narratively. Risk of bias was assessed using the revised Cochrane Risk of Bias 2 (RoB 2) tool and the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Seventeen studies met the inclusion criteria (11 RCTs and six observational studies). Meta-analysis of RCTs demonstrated that early LC did not significantly increase conversion to open surgery (odds ratio (OR) 0.90, 95% confidence interval (CI) 0.58-1.38; I² = 0%), bile leak (OR 1.80, 95% CI 0.69-4.66), bile duct injury (OR 0.61, 95% CI 0.15-2.48), mortality (OR 0.94, 95% CI 0.21-4.17), or postoperative complications (OR 0.73, 95% CI 0.38-1.40). In contrast, composite strategy morbidity, which incorporated waiting-period events, was significantly lower with early LC (OR 0.26, 95% CI 0.17-0.38; p < 0.001; I² = 0%). Total hospital stay was consistently reduced by approximately three to six days across all 11 RCTs. Observational studies supported same-admission surgery but were uniformly at serious risk of confounding. Overall, early LC appears surgically safe and substantially reduces composite strategy morbidity and hospital stays without increasing operative risk. The traditional 72-hour symptom threshold should not be considered an absolute contraindication to surgery. Further high-quality evidence is needed for patients presenting beyond 72 hours, older adults, and severity-stratified subgroups.