Selective preoperative assessment before early laparoscopic cholecystectomy: A narrative review

Table 2 Risk factors that should trigger formal preoperative assessment despite apparently low American Society of Anesthesiologists class

Domain	Examples	Rationale
Cardiorespiratory symptoms	Exertional chest pain, unexplained dyspnoea, syncope, decompensated heart failure, unstable asthma/COPD	May alter anaesthetic plan, investigation and perioperative monitoring
Functional capacity/frailty	Poor exercise tolerance, falls, unintentional weight loss, cognitive impairment, dependence in activities of daily living	ASA may underrepresent frailty-related risk
Medication complexity	Warfarin/DOACs, antiplatelets, insulin, immunosuppression, high-dose opioids	Requires perioperative planning and possible bridging/adjustment
Airway/anaesthetic history	Previous difficult airway, malignant hyperthermia risk, severe postoperative nausea/vomiting, previous ICU admission	Requires anaesthetic planning and documentation
Obesity and sleep-disordered breathing	Severe obesity, suspected OSA, obesity hypoventilation symptoms	May influence airway, postoperative monitoring and day-case suitability
Abnormal investigations	Unexplained anaemia, renal impairment, electrolyte disturbance, deranged liver function suggesting CBD stones	May require optimisation, ERCP or altered timing
Social/discharge concerns	No adult escort, poor understanding, language barriers, safeguarding concerns	May affect day-case/discharge safety

ASA: American Society of Anesthesiologists; COPD: Chronic obstructive pulmonary disease; DOACs: Direct oral anticoagulants; ICU: Intensive care unit; OSA: Obstructive sleep apnea; CBD: Common bile duct; ERCP: Endoscopic retrograde cholangiopancreatography.