Conversion of Robotic Distal Pancreatectomy: Predictors and Outcomes in an International Multicenter Study

Philip C Müller; Philipp Sedlaczek; Adrian T Billeter; Baiyong Shen; Jiabin Jin; Felix Nickel; Cristiano Guidetti; Emanuele Kauffmann; Julia Purchla; Caroline Berchtold; Christoph Tschuor; Paul Suno Krohn; Stefan K Burgdorf; Jan Philipp Jonas; Felix Julius Bussmann; Olivier Saint-Marc; Abdallah Iben-Khayat; Paul C M Andel; Izaak Quintus Molenaar; Ulrich Wellner; Tobias Keck; Beat Moeckli; Christian Toso; Fabrizio Di Benedetto; Valentina Valle; Pier Giulianotti; Didier Roulin; John Martinie; Martina Rama; Harish Lavu; Charles J Yeo; Parit T Mavani; Mihir M Shah; David A Kooby; Jin He; Ugo Boggi; Thilo Hackert; Inne H M Borel-Rinkes; Pierre-Alain Clavien; Beat P Müller; Christoph Kuemmerli

doi:10.1097/SLA.0000000000006821

Conversion of Robotic Distal Pancreatectomy: Predictors and Outcomes in an International Multicenter Study

Ann Surg. 2025 Jul 3. doi: 10.1097/SLA.0000000000006821. Online ahead of print.

Authors

Philip C Müller¹, Philipp Sedlaczek¹, Adrian T Billeter¹, Baiyong Shen², Jiabin Jin², Felix Nickel³, Cristiano Guidetti⁴, Emanuele Kauffmann⁵, Julia Purchla⁶, Caroline Berchtold¹, Christoph Tschuor⁷, Paul Suno Krohn⁷, Stefan K Burgdorf⁷, Jan Philipp Jonas⁸, Felix Julius Bussmann⁸, Olivier Saint-Marc⁹, Abdallah Iben-Khayat⁹, Paul C M Andel¹⁰, Izaak Quintus Molenaar¹⁰, Ulrich Wellner¹¹, Tobias Keck¹¹, Beat Moeckli¹², Christian Toso¹², Fabrizio Di Benedetto⁴, Valentina Valle¹³, Pier Giulianotti¹³, Didier Roulin^{14

15}, John Martinie¹⁴, Martina Rama¹⁶, Harish Lavu¹⁶, Charles J Yeo¹⁶, Parit T Mavani¹⁷, Mihir M Shah¹⁷, David A Kooby¹⁷, Jin He⁶, Ugo Boggi⁵, Thilo Hackert³, Inne H M Borel-Rinkes¹⁰, Pierre-Alain Clavien⁸, Beat P Müller¹, Christoph Kuemmerli¹

Affiliations

¹ Department of Surgery, Clarunis University Digestive Health Care Center, University Hospital Basel, Basel, Switzerland.
² Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
³ Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁴ Hepato-pancreato-biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
⁵ Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
⁶ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA.
⁷ Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
⁸ Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
⁹ Service de Chirurgie Digestive, Endocrinienne et Thoracique, Centre Hospitalier Régional, Orleans, France.
¹⁰ Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands.
¹¹ Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
¹² Department of Surgery, University Hospital of Geneva, Geneva, Switzerland.
¹³ Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
¹⁴ Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, USA.
¹⁵ Department of Visceral Surgery, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.
¹⁶ Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.
¹⁷ Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA.

PMID: 40607707
DOI: 10.1097/SLA.0000000000006821

Abstract

Objective: The aim of this study was to identify risk factors for conversion and assess its consequences on clinical outcomes after robotic distal pancreatectomy (RPD).

Summary of background data: RDP has gained popularity due to its lower conversion rate (3-8%) when compared to laparoscopic distal pancreatectomy (10-20%).

Methods: This retrospective multicenter study included RDPs performed at 16 international centers from May 2007 to March 2024. Perioperative outcomes of patients requiring conversion were compared to fully robotic RDP patients. Risk factors for conversion were identified by multivariable logistic regression analysis.

Results: Of 2,452 patients undergoing RDP, 75 (3.1%) required conversion to open surgery. In converted RDPs, operative time was longer (300 (243-376) vs. 180 (120-240) minutes; P<0.001), and blood loss was greater (500 (200-990) vs. 100 (50-200) ml; P<0.001). Converted patients experienced more overall complications (53% vs. 39%; P=0.017), major complications (41% vs. 25%; P<0.001), and a higher 90-day mortality (5% vs. 3%; P<0.001). Furthermore, both postoperative pancreatic fistula (35% vs. 18%; P<0.001) and delayed gastric emptying (10% vs. 3%; P<0.001) were more frequent in the conversion group. The rate of patients achieving textbook outcome was lower after conversion (57% vs. 74%; P=0.003). In the multivariable analysis, lesion size (>51 mm; OR 2.86 (95% CI 1.56-5.08)), BMI (>28 kg/m2; OR 3.03 (1.75-5.30)), previous abdominal surgery (OR 2.48 (1.31-4.51)), patients outside benchmark criteria (OR 2.09 (1.19-3.72)), and age (>62 years; OR 2.21 (1.24-4.05)) were associated with conversion.

Conclusion: This international cohort study confirmed a very low conversion rate for RDP. Yet, converted cases experienced substantially impaired postoperative outcomes, highlighting the need for adequate patient selection through validated difficulty scoring systems.

Keywords: Robotic surgery; clinical outcomes; conversion; distal pancreatectomy; pancreatic surgery.