The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4‐6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity‐matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best‐practice surgical techniques, adjunct intra‐operative imaging, and bail‐out options when performing LC.

Replacing residents or restructuring hospital care incurs substantial costs that are not specifically funded in conjunction with the duty hour and educational mandates of the past several years. This article attempts to estimate the large magnitude of these expenses. Teaching hospitals have relied heavily on their resident staff to meet their service needs. Nowhere has this been more prominent than in surgery, where trainees are traditionally expected to have a significant service responsibility in exchange for the privilege of participating in the operating room (OR), in effect, a contract to exchange service for training. Recently, however, various forces have altered this contract. The most dramatic has been the impact of work hour reduction for residents. After legislatively mandated duty hour restrictions in New York,¹ the Accreditation Council for Graduate Medical Education (ACGME) adopted national requirements for resident duty hours that went into effect in July 2003.² This change forced many teaching institutions to restructure their staffing, most often by adding physician extenders to replace service hours formerly supplied by resident staff. There is every reason to believe that work hours will be further reduced, and it seems likely that the relatively modest current restrictions on work hours will be increased.