Laparoscopic cholecystectomy is the first therapeutic option in gallstone disease. Acute cholecystitis is a risk factor for complication in laparoscopic cholecystectomy and a significantly associated predictive factor of conversion to open cholecystectomy1, which is a safer treatment alternative in those patients.

With great interest, I reviewed the retrospective case-control study by Morales-Maza et al.2 on the controversial subject of laparoscopic cholecystectomy conversion to open surgery that was conducted at a tertiary care hospital. The study proposed a risk factor analysis based on clinical, laboratory, and ultrasound parameters, concluding that patients above 50 years of age, male sex, and ultrasound findings of gallbladder wall thickening and the presence of pericholecystic fluid are factors for conversion to open cholecystectomy, with 84% sensitivity of the risk factor summation pathway.

In 2018, Al Masri et al.3 carried out a retrospective study in which they concluded that the predictive variables for conversion were advanced age, male sex, and significant comorbidities, such as chronic obstructive or restrictive lung disease and anemia, with hemoglobin levels below 9g/dl, as well as a history of previous laparotomies, resulting in a conversion rate of 1.03%. The most frequent intraoperative causes for conversion were the perception of difficult anatomy or inadequate visualization of structures due to the presence of severe adhesions or a significant inflammatory process. The patients that required conversion had longer periods of hospitalization.

In 2019, an international, multicenter, prospective study was conducted to evaluate an intraoperative scoring system to achieve a surgical classification to predict the indication for conversion of elective or emergency laparoscopic cholecystectomy to the open procedure. The scoring of cholecystitis severity was based on 4 components: the surgical appearance of the gallbladder (adhesions covering more than 50% of the gallbladder or less than 50%); distension/contraction (a distended or contracted gallbladder, impossibility to grasp the gallbladder without decompression, a stone larger than 1cm impacted in a Hartmann pouch); ease of access (body mass index above 30 or limitation due to adhesions from previous surgeries); and the presence of sepsis in the peritoneal cavity (biliary peritonitis or purulent fluid), as well as the presence of a cholecysto-enteric fistula. The total score was 10 points (G10). If the G10 system score was less than 2 points, the gallbladder surgery was classified as easy, a score of 2–4 points was classified as moderate, 5–7 points as difficult, and 8–10 points as extreme. Twenty-two percent of the patients were found to have gallbladder surgeries that were considered difficult or extreme. The surgeries were converted in 14% of the patients, but 33% of those conversions were in patients with G10 scores ≥54.

Developing predictive risk factor models that enable the identification of patients at a higher risk for conversion of laparoscopic cholecystectomy to open surgery has been very difficult. Risk factors must be correlated with operative findings that can lead to the complex decision of converting a cholecystectomy.