Predicting Conversion From Laparoscopic to Open Cholecystectomy: A Prospective Risk Factor Analysis and Scoring Model Formulation

Background Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallstone disease. However, a subset of cases requires conversion to open cholecystectomy (OC) due to anatomical challenges or intraoperative complications. Objective To identify the preoperative and intraoperative risk factors associated with conversion of LC to OC and propose a simple scoring system to predict high-risk cases. Methodology A prospective observational study was conducted in the Department of General Surgery, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, a tertiary center in Northern India serving mainly a rural population, from June 2023 to December 2024. Patients undergoing LC for symptomatic cholelithiasis were enrolled. Preoperative variables, including age, gender, comorbidities, previous abdominal surgery, and laboratory markers, were recorded. Intraoperative findings, such as gallbladder appearance, adhesions, Calot's triangle anatomy, presence of common bile duct (CBD) stones, cholecystoenteric fistula, and attainment of the critical view of safety (CVS), were analyzed. Statistical significance was set at <i>P </i>< 0.05. Results Of 318 patients, 33 (10.38%) required conversion to OC. Significant preoperative risk factors included previous abdominal surgery (<i>P </i>= 0.047) and elevated alkaline phosphatase (ALP) levels (<i>P </i>< 0.001). Intraoperative predictors such as a contracted gallbladder (<i>P </i>< 0.001), dense pericholecystic adhesions (<i>P </i>< 0.001), non-visualization of Calot's triangle (<i>P </i>< 0.001), failure to attain CVS (<i>P </i>< 0.001), CBD stones (<i>P </i>< 0.001), and cholecystoenteric fistula (<i>P </i>< 0.001) were strongly associated with conversion. A weighted scoring system was developed for risk stratification. Conclusions Conversion from laparoscopic to OC, though infrequent (10.38%), is crucial for patient safety in selected cases. Prior abdominal surgery and elevated alkaline phosphatase predicted conversion preoperatively, while dense adhesions, poor Calot's triangle visualization, failure to achieve the critical view of safety, cholecystoenteric fistula, and CBD stones were key intraoperative determinants. The proposed risk scoring system enables early identification of high-risk patients, improving surgical planning, decision-making, and outcomes.