Dear Editor,

I carefully reviewed the study entitled "Determinants of Conversion from Laparoscopic to Open Cholecystectomy: Türkiye Case" (1). Given that it encompasses a broad national patient population (within hospitals of the Turkish Ministry of Health), I believe it provides valuable data on the rates and risk factors for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). In reading this manuscript, I identified several points that merit further discussion.

Analyzing national data from the Ministry of Health to design a nationwide study undoubtedly yields significant results. However, one aspect I found lacking in this study is a clear grouping of surgeries by the type of healthcare institution (private hospitals, public hospitals, training and research hospitals, or university hospitals). These factors could also influence the likelihood of conversion from LC to OC. The low conversion rate of 1.1% reported here suggests that LC may have been performed by highly experienced surgeons or in high-volume centers and/or that patient selection was meticulous. This observation is noteworthy given that previous studies commonly report higher conversion rates (2-5). Furthermore, variables such as surgeon experience, annual hospital volume, and whether the procedure was an emergency or elective were not included in the analysis. The literature indicates that these factors can influence LC outcomes (6).

Evidence suggests that ethnic and regional differences can affect surgical outcomes (7). Given that this is a nationwide database study, conducting a regional analysis of cases could further strengthen the study. Additionally, when examining reasons for conversion, an important question is whether the patient presented with acute cholecystitis, underwent percutaneous cholecystostomy, or had prior surgery, as these factors have been shown to be relevant to the risk of conversion (8).

It also appears that no multivariable analyses were conducted. Implementing logistic regression or similar multivariable models would have been beneficial to control for potential interactions among age, sex, and comorbidities, thereby clarifying the independent risk factors (9). Moreover, the nature of the complications (e.g., bile duct injury, hemorrhage, infection) was not described in detail, leaving “complication” as a rather broad term. At a minimum, mentioning these points as limitations in the discussion section could help enhance the overall quality of the study.

This large-scale, nationwide retrospective investigation presents intriguing findings regarding the rate of conversion from laparoscopic to OC and addresses a critical issue. I congratulate the research team on their efforts and hope that these comments provide useful feedback to further enrich the article.