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 had been conducted at Shahida Islam Medical College, Lodhran, from October 2025 to March 2026. The study had evaluated clinical and perioperative factors associated with conversion from laparoscopic to open cholecystectomy among patients undergoing surgical management of acute cholecystitis. Medical records of eligible patients who had undergone laparoscopic cholecystectomy during the study period had been retrospectively reviewed.

Study Population and Sample Size

A total of 80 patients with acute cholecystitis who had undergone an attempted laparoscopic cholecystectomy had been included in the study. Patients had been categorized according to whether the laparoscopic procedure had been completed successfully or had required conversion to an open surgical approach. The conversion group had consisted of patients in whom the laparoscopic procedure could not be safely completed and an open cholecystectomy had subsequently been performed.

Inclusion and Exclusion Criteria

Patients aged 18 years or older with a confirmed diagnosis of acute cholecystitis who had undergone

                                                                                                                          attempted    laparoscopic    cholecystectomy    had    been

included.

The diagnosis had been established on the basis of clinical findings, laboratory investigations, and appropriate imaging, as documented in the medical records. Patients with gallbladder malignancy, a history of previous upper abdominal surgery, incomplete or missing medical records, or a preoperative plan for open cholecystectomy had been excluded. Patients for whom laparoscopic surgery had not been attempted had also not been considered for assessment of conversion predictors.

Data Collection

Relevant information had been extracted from hospital medical records using a structured data collection proforma. Demographic variables had included age and sex. Clinical variables had included presenting symptoms, duration of symptoms, fever, right upper quadrant abdominal pain, nausea or vomiting, and relevant comorbid conditions. Laboratory parameters, including total leukocyte count, hemoglobin level, liver function tests, and other routinely documented biochemical investigations, had been recorded where available.

Radiological findings had been reviewed, particularly ultrasonographic evidence of gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstones, and other features suggestive of severe inflammation. Operative characteristics, including difficulty in dissection, dense adhesions, unclear anatomy in the Calot's triangle, bleeding, and other intraoperative difficulties, had also been documented when available. The primary outcome had been conversion from laparoscopic to open cholecystectomy.

Surgical Outcome Assessment

All patients had initially undergone an attempted laparoscopic cholecystectomy according to the institutional surgical protocol. Conversion had been considered necessary when adequate visualization or safe dissection 

could not be achieved laparoscopically, when significant bleeding could not be safely controlled, when severe inflammation or adhesions obscured the anatomy, or when the operating surgeon had determined that continuation of the laparoscopic procedure posed an unacceptable risk of injury to surrounding structures. Patients had subsequently been classified into successful laparoscopic and converted-to-open groups.

Statistical Analysis

Data had been entered, coded, and analyzed using Statistical Package for the Social Sciences (SPSS) version

26.0. Continuous variables had been summarized using mean and standard deviation, whereas categorical variables had been presented as frequencies and percentages. Comparisons between patients who had undergone successful laparoscopic cholecystectomy and those who had required conversion to open surgery had been performed using the independent-samples t test or an appropriate non-parametric test for continuous variables, while the chi-square test or Fisher's exact test had been used for categorical variables. Factors associated with conversion had been assessed using appropriate regression analysis, and odds ratios with 95% confidence intervals had been calculated where applicable. A p-value of <0.05 had been considered statistically significant.

Ethical Considerations

The study had been conducted in accordance with accepted ethical principles for retrospective clinical research. Confidentiality of patient information had been maintained throughout the data collection and analysis process. Patient identifiers had not been included in the analytical dataset, and the medical records had been accessed solely for research purposes. Ethical approval had been obtained from the relevant institutional authority before commencement of the study.

A total of 80 patients who had undergone laparoscopic cholecystectomy for acute cholecystitis during the study period were included in the analysis. The mean age of the participants had been 46.8 ± 13.2 years. Females constituted the majority of th e study population, with 47 (58.8%) patients, whereas 33 (41.3%) had been males. Conversion from laparoscopic to open cholecystectomy had occurred in 14 (17.5%) patients, while 66 (82.5%) had completed the procedure laparoscopically.

Table 1. Demographic and Clinical Characteristics of the Study Participants According to Conversion Status:

WBC = white blood cell; CRP = C-reactive protein; SD = standard deviation.

Table 1 showed that patients who had required conversion to open cholecystectomy had generally presented with more severe clinical and inflammatory features. The mean age of patients in the conversion group had been higher than that of patients who had completed laparoscopic surgery (54.8 ± 14.3 versus 45.1 ± 12.5 years), and the proportion aged ≥60 years had been significantly greater among those requiring conversion (35.7% versus 13.6%, p<0.05). Sex distribution had not differed significantly between the two groups, indicating that gender had not been an important determinant of conversion in this cohort.

Diabetes mellitus had been present in 57.1% of patients who had undergone conversion compared with 24.2% among those who had remained laparoscopic, demonstrating a significant association. Similarly, prolonged symptom duration exceeding 72 hours had been considerably more frequent in the conversion group (64.3%) than in the non-conversion group (27.3%). An elevated WBC count of >15×10⁹/L had also been observed more frequently among patients requiring conversion (64.3% versus 24.2%, p<0.05). Elevated CRP levels had been present in 78.6% of converted patients compared with 40.9% of those without conversion.

Ultrasonographic findings had demonstrated similarly important associations. Gallbladder wall thickness ≥4 mm had been observed in 71.4% of patients who had required conversion, compared with 28.8% of patients who had completed laparoscopic surgery. Pericholecystic fluid had been detected in 71.4% of the conversion group compared with 19.7% of the non-conversion group. Impacted gallstones had also been substantially more common among converted patients (57.1% versus 19.7%, p<0.05). These findings had indicated that advanced local inflammation and difficult gallbladder pathology had increased the likelihood of conversion.

Table 2. Multivariable Logistic Regression Analysis of Independent Predictors of Conversion:

WBC = white blood cell.

Multivariable logistic regression analysis had identified four variables as independent predictors of conversion from laparoscopic to open cholecystectomy. Patients with symptom duration exceeding 72 hours had 3.52 times higher odds of conversion than those with shorter symptom duration (AOR=3.52; 95% CI: 1.28–9.71). Gallbladder wall thickness ≥4 mm had demonstrated the strongest association among the evaluated independent predictors, with patients having 4.18-fold higher odds of conversion (AOR=4.18; 95% CI: 1.49–11.76).

Diabetes mellitus had also remained independently associated with conversion after adjustment for other clinical factors. Diabetic patients had nearly three times higher odds of requiring conversion (AOR=2.94; 95% CI: 1.08–8.01). Similarly, a WBC count >15×10⁹/L had been associated with approximately threefold increased odds of conversion (AOR=3.11; 95% CI: 1.17–8.29).

Overall, the findings had demonstrated that conversion had occurred in 17.5% of patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Older age, diabetes mellitus, prolonged symptom duration, marked leukocytosis, elevated CRP, increased gallbladder wall thickness, pericholecystic fluid, and impacted gallstones had been significantly associated with conversion on comparative analysis. After adjustment for potential confounding factors, prolonged symptoms, gallbladder wall thickness ≥4 mm, diabetes mellitus, and WBC count >15×10⁹/L had remained independent predictors of conversion. These findings had suggested that both systemic inflammatory severity and local gallbladder pathology had played important roles in determining the technical feasibility of laparoscopic 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

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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