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Predictors and reasons for conversion of laparoscopic to open cholecystectomy: a five-year cohort study
Kasim O Hussein Al-Ali1, Haider Y Naeif Kurkoosh1, Mohammed Mohaibes2
1College of Medicine, Al-Muthanna University- Al-Hussein Teaching Hospital, CABMS, Samawa, Iraq.
Background:
Conversion from laparoscopic to open cholecystectomy (LC to OC) is an important surgical outcome that reflects procedural complexity and patient risk. While conversion predictors have been studied internationally, context-specific data from Iraq remain limited.
Objectives:
To determine the conversion rate in an Iraqi cohort, identify independent preoperative predictors, develop a simplified risk score, and systematically categorize intraoperative conversion reasons.
Methods:
A retrospective cohort study was conducted on 945 consecutive patients who underwent LC between December 2020 and December 2025 at Al-Hussein Teaching Hospital, Iraq. All cases were either purely elective procedures for symptomatic gallstone disease or urgent-elective cases (patients with acute cholecystitis treated conservatively then operated 3-7 days after symptom onset).
Results:
Conversion occurred in 87 of 945 cases (9.2%; 95% CI 7.4-11.2%). Male sex (adjusted odds ratio [aOR] 2.10, 95% CI 1.30-3.40, p = 0.002), prior abdominal surgery (aOR 1.65, 95% CI 1.05-2.60, p = 0.030), and ASA class III (aOR 1.80, 95% CI 1.00-3.25, p = 0.049) were independent predictors. Urgent-elective status was not independently associated with conversion (aOR 1.12, 95% CI 0.68-1.85, p = 0.650). The most common intraoperative reasons for conversion were technical factors: laparoscopic decompression or aspiration was attempted but inadequate to achieve safe dissection in cases of distended or thick-walled gallbladder (16.1%), gallbladder neck stones with severe inflammation (13.8%), and dense adhesions from prior surgery with attempted laparoscopic adhesiolysis exceeding 20-30 min without safe progression (12.6%). In 17 cases (19.5%), these cases were included in the primary analysis because the underlying surgical indication was present. Surgeon-documented procedural limitations related to informed consent documentation (19.5%) were also identified.
Conclusions:
In this Iraqi cohort, the LC-to-OC conversion rate was 9.2%. Male sex, prior abdominal surgery, and higher ASA classification were key preoperative predictors. The simplified risk score provides a pragmatic tool for preoperative risk stratification in resource-limited settings.
