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Background Laparoscopic appendectomy (LA) has become the standard of care for the management of acute appendicitis in adult patients. Despite the increasing experience in laparoscopy, conversion to open surgery might still occur. We aimed to identify preoperative and intraoperative risk factors for conversion and determine surgical outcomes in this population. Methods We performed a retrospective analysis of a consecutive series of patients undergoing LA during the period 2006–2020. The cohort was divided into two groups: patients who underwent a fully laparoscopic appendectomy (FLA) and patients who were converted to open appendectomy (CA). Demographics, perioperative variables and postoperative outcomes were compared between both groups. Independent risk factors for conversion were determined by logistic regression analysis. Results A total of 2193 patients were included for analysis; 2141 (98%) underwent FLA and 52 (2%) CA. Conversion rates decreased significantly over time ( p = 0.006). Patients with CA had significantly higher overall postoperative morbidity rates (FLA 14.9% vs. CA 48.0%, p < 0.0001) and longer mean length of hospital stay (FLA 1.7 vs. CA 5 days). In the multivariate analysis, obesity ( p < 0.001), previous abdominal operations ( p = 0.013), peritonitis ( p = 0.003) and complicated appendicitis ( p < 0.001) were independent risk factor for conversion. Conclusions Although conversion from laparoscopic to open appendectomy is infrequent and has decreased over time, it is associated with significantly higher postoperative morbidity. Patients with previous abdominal operations, obesity and complicated appendicitis should be thoroughly advised about the higher risk of conversion.

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