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

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.