Surgeons can confidently perform proactive emergency laparoscopic cholecystectomy for complex acute cholecystitis, showing strong outcomes even in high-risk patients.

• Among 721 patients, the overall complication rate was just 6.9%, with severe complications at 1.2%.
• Patients older than 80 had no higher complication rates (p = 0.14) compared to younger patients.
• Indocyanine green cholangiography significantly reduced partial resection rates (0.7% vs. 6.3%, p = 0.005) and intraoperative blood loss.

This approach emphasizes safety in managing complex cases, supporting a shift towards proactive surgical intervention.