Background: Elderly complains of cardiopulmonary diseases, and the incidence of emergent gallbladder diseases increases with age. Laparoscopic cholecystectomy is the usual approach in dealing with cholelithiasis that significantly replaces the open approach even in acute emergency gallbladder diseases. This study aimed to compare between initial Fundus first cholecystectomy followed by Calot dissection vs Calot first cholecystectomy in Emergency laparoscopic cholecystectomy with low-pressure pneumo-peritoneum in cardiopulmonary risk patients regarding intraoperative data and postoperative data complications. Methods: This prospective randomized controlled study was carried out on 470 cases who underwent emergent laparoscopic cholecystectomy. The patients were divided into Group A: fundus-Calot group (235cases) and Group B (235cases): classical Calot first approach. Results: Operation time was significantly shorter in the 1st group (p=0.00). Intraoperative cystic artery bleeding, liver bleeding and omental vessel bleeding occurred in 2(0.8%), 0 (0.0%) and 2(0.8%) in group A and 18(7.6%), 16(6.8%) and 6(2.5%) in group B respectively. Iatrogenic bile duct injuries occurred in 2 cases (0.8%) in group A and 11 cases (4.6%) in group B. Liver injury, colonic injury, and duodenal injury occurred in 22(9.3%), 4(1.7%), and 6(2.5%) in group B, respectively. Conversion to open surgery occurred in 9 cases (3.8%) of group A and 34 cases (14%) in group B. Bile leakage, wound infection, intra-abdominal collection, and port site hernia occurred in 4 cases(1.7%),8 cases(3.4%) and 8 cases (3.4%) in group A and 12 cases (5.1%)16 cases(6.8%) and 16 cases(6.8%) in group B respectively. Biliary stricture occurred in 4 cases (1.7%) in group A and 33 cases (14%) in group B. Conclusion: Laparoscopic initial Fundus first cholecystectomy is an excellent and safe approach.