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Although elective laparoscopic cholecystectomy is today's gold standard for the treatment of symptomatic cholelithiasis, its safety and effectiveness for acute cholecystitis remain controversial. The authors present a retrospective study comparing laparoscopic cholecystectomy in the acute versus the elective setting. A total of 605 patients were treated surgically for gallstone disease between August 1991 and January 1999. A total of 269 patients (44.5%) underwent surgery for acute cholecystitis as soon as possible after diagnosis, and elective cholecystectomy was performed on 336 patients (55.5%) for symptomatic gallstones. Initial open cholecystectomy was performed on 52 (19.3%) of the acute patients and 16 (4.8%) of the elective patients. Laparoscopic cholecystectomy was attempted on 217 of the acute patients (80.7%), with 11 cases (5.1%) converted to open cholecystectomy, and on 320 (95.2%) of the elective patients, with 6 cases (1.9%) converted to open cholecystectomy. The mean (±SD) operative time for the acute and elective patients was 105 (±38) and 85 (±21) minutes, respectively (P < 0.05). There was no perioperative mortality in either laparoscopic group. Surgical complications related to laparoscopic cholecystectomy in the acute and elective groups occurred in six (2.9%) and eight (2.5%) cases, respectively (P = NS). The current study shows that early laparoscopic cholecystectomy for acute cholecystitis is safe and efficient. Low conversion rates can be maintained with strict guidelines for appropriate patient selection, adequate experience, and proper laparoscopic technique.