Retrospective analysis of risk factors predicting operative difficulty and conversion to open surgery in laparoscopic cholecystectomy

INTRODUCTION: Laparoscopic cholecystectomy (LC) may become technically demanding because of inflammation, adhesions, or altered anatomy. Identifying preoperative risk factors for operative difficulty and conversion to open surgery is important for surgical planning and patient counseling. This study aimed to evaluate these two outcomes separately and identify their independent predictors.
METHODS: This retrospective study reviewed 303 consecutive patients who underwent LC at a tertiary training and research hospital over a five-year period (January 2020–August 2025). Operative difficulty was defined as the presence of intraoperative adhesions, edema/inflammation, abscess, or bleeding. Group comparisons were performed using the Mann–Whitney U and Fisher’s exact tests, and multivariable logistic regression was used to identify independent predictors.
RESULTS: Operative difficulty was observed in 93 patients (30.7%), and conversion was required in 11 (3.6%). In multivariable analysis, a history of cholecystitis was the only independent predictor of operative difficulty (OR, 3.15; 95% CI, 1.64–6.04; p<0.001). For conversion, emergency admission (OR, 19.81; 95% CI, 4.49–87.40; p<0.001) and ASA score (OR, 6.77; 95% CI, 2.10–21.86; p=0.001) were independent predictors. CRP, gallbladder wall thickness, and pericholecystic fluid were significant in univariable analyses for both outcomes, whereas NLR was significant only for conversion.
DISCUSSION AND CONCLUSION: Operative difficulty and conversion have distinct predictive profiles. A history of cholecystitis predicts intraoperative difficulty, whereas emergency admission and a higher ASA score predict conversion. Preoperative inflammatory markers and imaging findings may further assist in risk stratification.

Keywords: ASA score, cholecystitis, conversion, laparoscopic cholecystectomy, operative difficulty, risk factors