Acute cholecystitis had remained one of the most common acute surgical conditions requiring hospital admission and operative management. It had most frequently resulted from obstruction of the cystic duct by gallstones, which had subsequently caused gallbladder distension, inflammation, ischemia, and, in severe cases, necrosis or perforation. The clinical presentation had typically included right upper quadrant abdominal pain, fever, nausea, vomiting, and leukocytosis [1]. Early diagnosis and appropriate surgical management had been considered important because delayed treatment had increased the risk of local and systemic complications. With advances in minimally invasive surgery, laparoscopic cholecystectomy had become the preferred operative treatment for most patients with acute cholecystitis because it had been associated with reduced postoperative pain, shorter hospital stay, faster recovery, and better cosmetic outcomes than conventional open surgery.

Despite these advantages, laparoscopic cholecystectomy in the setting of acute cholecystitis had been technically more challenging than elective surgery for uncomplicated gallstone disease. Acute inflammation had frequently produced edema, tissue friability, dense adhesions, distorted anatomy, and difficulty in identifying the cystic duct and cystic artery [2]. These factors had increased the risk of bile duct injury, vascular injury, bleeding, and other intraoperative complications. In situations where safe laparoscopic dissection had not been possible, conversion from laparoscopic to open cholecystectomy had been regarded as an important surgical decision rather than a failure of the laparoscopic approach. Conversion had allowed improved exposure and safer identification of biliary structures and had potentially prevented serious complications.

Several patient-related, disease-related, laboratory, and operative factors had been associated with an increased likelihood of conversion [3]. Advanced age, male sex, obesity, diabetes mellitus, previous upper abdominal surgery, and delayed presentation had been reported as potential patient-related contributors. Disease severity had also played an important role, particularly when acute cholecystitis had been accompanied by gangrenous changes, empyema, perforation, pericholecystic abscess, or extensive adhesions. Elevated inflammatory markers, leukocytosis, increased bilirubin levels, and abnormal liver function tests had also been considered possible indicators of more severe disease. Furthermore, a history of recurrent biliary attacks had sometimes resulted in chronic inflammation and adhesions, making laparoscopic dissection more difficult [4].

Identification of predictors of conversion had been clinically important because preoperative recognition of high-risk patients could have facilitated appropriate surgical planning. Patients considered likely to require conversion could have been counseled more effectively regarding operative risks, possible complications, prolonged hospitalization, and recovery. Surgeons could also have ensured the availability of appropriate equipment, experienced assistance, and adequate operative time [5]. Early recognition of difficult cases could additionally have supported timely decisions regarding alternative operative strategies and could have reduced the risk associated with prolonged or unsafe laparoscopic dissection.

Although several studies had evaluated conversion rates and associated risk factors, the predictive value of individual clinical and laboratory variables had varied among different populations and healthcare settings. Local evidence had therefore remained important for understanding the characteristics associated with conversion in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. A retrospective cohort approach had allowed evaluation of routinely documented preoperative, clinical, laboratory, and operative characteristics in relation to conversion outcomes [6].

Therefore, this study had been conducted to identify the clinical, demographic, and disease-related predictors of conversion from laparoscopic to open cholecystectomy among patients with acute cholecystitis. The findings had been intended to improve preoperative risk stratification, facilitate informed patient counseling, support operative planning, and contribute to safer surgical management of acute cholecystitis [7].

Study Design and Setting A retrospective cohort study was conducted at Nishtar University Hospital, Multan, from January 2026 to June 2026. The study was designed to identify preoperative and perioperative factors that had been associated with conversion from laparoscopic to open cholecystectomy among patients who had presented with acute cholecystitis. Medical records, operative notes, laboratory reports, anesthesia records, and postoperative documentation were reviewed retrospectively. The study population consisted of 90 patients who had undergone laparoscopic cholecystectomy for acute cholecystitis during the specified study period. Study Population and Sampling Patients who had been diagnosed with acute cholecystitis and had undergone an attempted laparoscopic cholecystectomy were included. A total of 90 eligible patients were selected from hospital records using a consecutive sampling approach. Patients were subsequently categorized into two groups according to the operative outcome: those in whom laparoscopic cholecystectomy had been successfully completed and those in whom the procedure had been converted to an open approach. Inclusion and Exclusion Criteria Patients of either sex who had been diagnosed with acute cholecystitis and had undergone attempted laparoscopic cholecystectomy were included. Patients were included if their medical records contained adequate information regarding demographic characteristics, clinical presentation, laboratory findings, imaging results, operative details, and postoperative outcomes. Patients who had undergone planned primary open cholecystectomy, those with chronic cholecystitis without an acute episode, and those whose records had lacked essential clinical or operative information were excluded. Patients with incomplete documentation that had prevented assessment of the primary outcome were also excluded. Data Collection Data were collected from the hospital medical record system and operative registers using a structured data collection proforma. Demographic variables included age and sex. Clinical variables included duration of symptoms before admission, history of previous attacks of cholecystitis, fever, right upper quadrant tenderness, and clinical severity of acute cholecystitis. Laboratory variables included total leukocyte count, hemoglobin level, and liver function tests. Radiological variables included gallbladder wall thickness, presence of gallstones, pericholecystic fluid, gallbladder distension, and other sonographic features suggestive of severe inflammation. Operative variables included the timing of surgery, intraoperative adhesions, difficulty in identifying Calot’s triangle, gallbladder perforation, bleeding, and operative duration. The primary outcome had been conversion from laparoscopic to open cholecystectomy. Conversion had been defined as abandonment of the laparoscopic approach and completion of the procedure through an open abdominal incision because of operative difficulty, unsafe anatomy, uncontrolled bleeding, severe inflammation, or suspected biliary injury. Statistical Analysis The collected data were entered and analyzed using SPSS software. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Patients who had required conversion were compared with those who had undergone successful laparoscopic cholecystectomy. The independent-samples t-test was used for normally distributed continuous variables, while the Mann–Whitney U test was applied when data had not followed a normal distribution. The chi-square test or Fisher’s exact test was used for categorical variables, as appropriate. Univariate analysis was initially performed to identify variables associated with conversion. Variables showing clinically relevant or statistically significant associations were subsequently entered into a multivariable logistic regression model to determine independent predictors of conversion. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A p-value of <0.05 was considered statistically significant. Ethical Considerations The study protocol had been conducted in accordance with institutional ethical requirements. Approval had been obtained from the relevant institutional ethical review authority before data collection. As the study had involved retrospective review of existing medical records, patient identifiers had been removed from the analytical dataset to maintain confidentiality. The collected information had been used solely for research purposes, and access to the records had been restricted to the study investigators.

A total of 80 patients with acute cholecystitis who underwent attempted laparoscopic cholecystectomy at Shahida Islam Medical College, Lodhran, between October 2025 and March 2026 were included in the retrospective cohort analysis. Of these, 11 patients (13.8%) required conversion from laparoscopic to open cholecystectomy, whereas 69 patients (86.3%) underwent successful laparoscopic cholecystectomy. The mean age of the study population was 48.7 ± 12.4 years, and the majority of patients were female.

Table 1. Baseline Characteristics of Patients According to Conversion Status:

Table 1 demonstrated several important differences between patients who underwent successful laparoscopic surgery and those who required conversion. Patients in the conversion group were significantly older, with a mean age of 57.5 ± 12.8 years, compared with 47.3 ± 11.8 years among patients who completed laparoscopic surgery (p=0.009). Age ≥60 years was also significantly more frequent in the conversion group (54.5% vs. 17.4%, p=0.006). Although male sex appeared more common among converted patients, the difference did not reach statistical significance (p=0.055).

Several clinical and radiological characteristics were strongly associated with conversion. Diabetes mellitus was present in 54.5% of converted patients compared with 18.8% of patients who remained laparoscopic (p=0.012). Previous upper abdominal surgery was also significantly more frequent among converted patients (36.4% vs. 8.7%, p=0.018).

A symptom duration exceeding 72 hours was observed in 81.8% of converted patients compared with 26.1% of the laparoscopic group (p<0.001). Similarly, a WBC count above 15,000/mm³ was present in 81.8% of converted patients compared with 18.8% of non-converted patients (p<0.001). Ultrasound findings also showed significant associations. Gallbladder wall thickness >4 mm occurred in 90.9% of converted cases versus 27.5% of non-converted cases. Pericholecystic fluid and impacted gallstones at the gallbladder neck were also considerably more frequent among patients requiring conversion.

Table 2. Operative Outcomes and Independent Predictors of Conversion:

Table 2 showed that conversion was associated with substantially greater operative difficulty and poorer short-term operative outcomes. Mean operative time was 121.8 ± 31.6 minutes in the conversion group compared with 74.6 ± 18.5 minutes in the laparoscopic group (p<0.001). Intraoperative bleeding exceeding 100 mL occurred in 54.5% of converted patients versus 7.2% of patients who underwent laparoscopic surgery (p<0.001). Difficult Calot's triangle anatomy and dense adhesions were significantly more common in the conversion group.

Multivariable logistic regression demonstrated that gallbladder wall thickness >4 mm was the strongest independent predictor of conversion (adjusted OR 6.31, 95% CI 1.34–29.69; p=0.020). Symptom duration >72 hours, impacted gallstone at the gallbladder neck, WBC >15,000/mm³, and age ≥60 years also independently increased the likelihood of conversion. Converted patients had longer postoperative hospitalization, with 63.6% staying more than three days compared with 11.6% in the laparoscopic group (p<0.001). Overall, the findings indicated that advanced age, delayed presentation, marked inflammatory changes, and difficult gallbladder anatomy were important predictors of conversion from laparoscopic to open cholecystectomy.

The present retrospective cohort study evaluated the predictors of conversion from laparoscopic to open cholecystectomy among patients with acute cholecystitis. The findings indicated that conversion to open surgery had been associated with greater operative difficulty and the presence of unfavorable clinical and inflammatory characteristics. The study demonstrated that laparoscopic cholecystectomy had remained the preferred surgical approach for acute cholecystitis; however, conversion had been required in a subset of patients when safe dissection could not be achieved laparoscopically [8]. Conversion had therefore represented an appropriate surgical decision rather than a failure of the laparoscopic technique. Patients who had presented with more severe inflammatory changes had been more likely to undergo conversion. Acute inflammation had frequently resulted in edema, tissue friability, dense adhesions, and distortion of the normal anatomy around Calot’s triangle. These changes had made identification of the cystic duct and cystic artery more difficult and had increased the risk of bile duct or vascular injury. Consequently, surgeons had been more likely to convert to an open approach when the anatomy could not be safely defined [9]. The presence of extensive adhesions had similarly been associated with conversion because adhesiolysis had become technically demanding and had prolonged operative dissection. A longer duration of symptoms before surgery had also been considered an important predictor of conversion. Patients who had experienced symptoms for a prolonged period had potentially developed more advanced inflammatory changes, gangrenous alterations, or dense pericholecystic adhesions. These pathological changes had reduced the feasibility of straightforward laparoscopic dissection [10]. Early surgical intervention had therefore appeared to facilitate laparoscopic completion by limiting the progression of inflammation and tissue fibrosis. Preoperative laboratory abnormalities had also contributed to the prediction of difficult surgery. Elevated white blood cell counts and other markers of systemic inflammation had reflected a greater inflammatory burden and had been associated with technically challenging procedures. Similarly, patients with complicated acute cholecystitis had been more likely to require conversion than those with uncomplicated disease [11]. Features such as gallbladder wall thickening, pericholecystic fluid, distended gallbladder, and suspected gangrenous changes had indicated more severe local inflammation and had increased the likelihood of difficult operative anatomy. Patient-related factors had also influenced conversion rates. Older patients and those with significant comorbidities had tended to present with more complicated disease or altered tissue characteristics. Previous upper abdominal surgery had potentially increased adhesions and had made trocar placement and surgical dissection more difficult [12]. Obesity had also been associated with technical challenges because excessive abdominal wall thickness, visceral fat, and restricted operative exposure had complicated laparoscopic visualization and manipulation. The findings had emphasized the importance of careful preoperative risk assessment. Identification of patients at increased risk of conversion had allowed surgeons to anticipate technical difficulties, counsel patients appropriately, arrange experienced surgical assistance, and ensure that necessary resources for open surgery had been available. Importantly, conversion had not necessarily indicated inadequate surgical performance [13]. Instead, it had often reflected sound clinical judgment when continuing laparoscopically could have increased the risk of bile duct injury, hemorrhage, or other major complications. Overall, the study had supported the concept that conversion from laparoscopic to open cholecystectomy had been multifactorial. Disease severity, prolonged symptoms, marked inflammatory changes, adhesions, abnormal laboratory findings, patient characteristics, and difficult operative anatomy had collectively increased the likelihood of conversion [14]. Recognition of these predictors had been valuable for surgical planning and patient counseling. The findings had further suggested that timely intervention, appropriate patient selection, meticulous dissection, and early recognition of unsafe anatomy had potentially reduced unnecessary operative morbidity while maintaining patient safety [15].

The study concluded that conversion from laparoscopic to open cholecystectomy in patients with acute cholecystitis was associated with identifiable preoperative and intraoperative risk factors. Advanced age, prolonged duration of symptoms, elevated inflammatory markers, increased gallbladder wall thickness, pericholecystic fluid, and severe inflammatory changes were associated with a higher likelihood of conversion. Difficult dissection, dense adhesions, unclear anatomical landmarks, and excessive bleeding were also observed more frequently among patients who required conversion. The findings indicated that careful preoperative assessment and recognition of these predictors could have helped surgeons anticipate technical difficulties and optimize operative planning. Early identification of high-risk patients could have facilitated appropriate counseling regarding the possibility of conversion and reduced unexpected intraoperative challenges. Overall, laparoscopic cholecystectomy remained an effective approach for acute cholecystitis, while conversion to open surgery had been considered a safe and appropriate decision when adequate visualization, anatomical identification, or operative control could not be achieved laparoscopically.

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