True statements about the surgical management of patients with acute calculous cholecystitis include:

B. Antibiotic therapy should be initiated as soon as the diagnosis is made.

C. Dissection of the gallbladder is facilitated by decompression of the organ with the use of a trocar.

DISCUSSION: Cholecystectomy should be done in an otherwise healthy patient as soon as the diagnosis is made and the patient is properly prepared for surgery. However, patients who have one or more significant risk factors such as a recent myocardial infarction, unstable angina, clinically significant coronary artery disease, or cirrhosis should not have immediate cholecystectomy unless they do not improve within 24 to 36 hours in response to antibiotic administration and supportive care. Antibiotic administration should commence as soon as the diagnosis is made and should be continued for 24 hours postoperatively—or for 7 days if significant peritonitis is present. This use of antibiotics has significantly reduced septic complications after cholecystectomy for acute cholecystitis. In most cases the gallbladder is tensely distended, making visualization and dissection of the cystic duct area difficult and perhaps dangerous. Decompression of the gallbladder by insertion of a needle facilitates retraction and dissection of the gallbladder. Although some advise that operative cholangiography be done only on a selective basis, its routine use helps to delineate anatomy and facilitates detection of an occasionally unsuspected bile duct stone. Accordingly, it is used routinely in elective cases. In acute cholecystitis, however, the biliary duct system may be very friable, and operative cholangiography should be done only when it is safe to do so.