Selective preoperative assessment before early laparoscopic cholecystectomy: A narrative review

Table 1 Guideline synthesis relevant to selective preoperative assessment

Guideline/source	Core recommendation	Relevance to selective assessment	Gap
NICE CG188 gallstone disease[1]	Supports definitive management with laparoscopic cholecystectomy and early surgery in acute presentations	Strengthens the argument that avoidable pathway delay matters	Does not specify anaesthetic clinic criteria
NICE NG45 preoperative tests[2]	Recommends selective testing based on surgical grade and comorbidity	Supports risk-based rather than universal investigation	Focuses on tests rather than full clinic attendance
WSES 2020 acute cholecystitis[3]	Supports early laparoscopic cholecystectomy when feasible	Aligns with streamlined access to surgery	Does not define pre-assessment omission criteria
Tokyo Guidelines 2018[4,5]	Provides severity grading and surgical management principles	Emphasises patient selection and safe cholecystectomy	Does not address direct-to-surgery assessment pathways
ASA preanaesthesia evaluation[10,11]	Evaluation should be appropriate to patient and procedure	Supports tailored evaluation and escalation	Requires local implementation detail
AUGIS acute gallstone pathway[9]	Promotes timely management of acute gallstone disease	Relevant to United Kingdom Hot Gallbladder Pathway design	Implementation varies by resources

ASA: American Society of Anesthesiologists.

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.

Table 3 Objective findings and limitations of the illustrative United Kingdom Hot Gallbladder Pathway service evaluation

Aspect	Objective finding or interpretation
Cohort	511 adults undergoing laparoscopic cholecystectomy, January 2020-January 2025
Risk distribution	401 ASA I-II (78.5%); 110 ASA III-IV (21.5%)
Assessment pathway	334 (65.4%) without formal clinic-based pre-assessment; 177 (34.6%) with formal assessment; all ASA III-IV patients formally assessed
Recorded outcomes	No anaesthetic-related adverse event identified; one cancellation (0.2%), unrelated to anaesthetic factors
Interpretation	Supports feasibility in a selected cohort; does not establish equivalence or safety for rare events
Unmeasured outcomes	Waiting time, attributable recurrent admission, patient-reported outcomes and cost-effectiveness
Key limitations	Retrospective, single-trust, clinician-selected, potential ASA misclassification and rare-event underpowering

ASA: American Society of Anesthesiologists.

Table 4 Suggested eligibility criteria for direct listing without routine clinic-based pre-assessment

Criterion	Direct listing suitable when	Formal assessment required when
ASA status	ASA I-II with stable or absent comorbidity	ASA III-IV or uncertain classification
Functional capacity	Good exercise tolerance and no unexplained symptoms	Poor functional capacity, dyspnoea, chest pain, syncope
Medication	Simple medication profile, no complex anticoagulation	Warfarin/DOAC complexity, antiplatelet uncertainty, insulin complexity
Investigations	Recent blood tests reviewed and acceptable	Unexplained anaemia, renal impairment, electrolyte abnormality, suspected CBD stones
Anaesthetic history	No previous difficult airway or major anaesthetic complication	Previous difficult airway, malignant hyperthermia risk, severe postoperative complication
Frailty/social factors	Independent, adequate discharge support	Frailty, cognitive impairment, safeguarding or discharge concerns

ASA: American Society of Anesthesiologists; DOAC: Direct oral anticoagulant; CBD: Common bile duct.

Table 5 Practical recommendations and evidence of strength

Recommendation	Suggested approach	Strength of rationale
Direct listing for selected low-risk patients	ASA I-II, no red flags, recent investigations reviewed, same-day anaesthetic confirmation	Moderate; supported by indirect evidence and service experience
Formal assessment for higher-risk patients	ASA III-IV, frailty, unstable systemic disease, complex medications or airway concerns	Strong; consistent with perioperative medicine principles
Do not rely on ASA alone	Add comorbidity, frailty, functional capacity and medication review	Strong; ASA limitations are well documented
Prospective audit	Track clinical, operational, economic and patient-reported outcomes	Essential for governance and generalisability
Digital triage with oversight	Use electronic questionnaires and EPR integration; retain clinician review	Emerging; promising but requires validation

ASA: American Society of Anesthesiologists; EPR: Enterprise resource planning.