Background: Conversion to laparotomy during robotic pancreatoduodenectomy (RPD) carries important clinical implications, yet its incidence, predictors, and consequences in elderly and/or obese patients remain poorly characterized. This study aimed to define the conversion rate, identify preoperative predictors, and assess the impact of conversion on postoperative outcomes in elderly and/or obese surgically high-risk patients undergoing attempted RPD. Methods: A retrospective analysis was performed using a multi-institutional database. Patients were included if they underwent attempted RPD and met at least one high-risk criterion: age ≥ 80 years and/or BMI ≥ 30 kg/m2. Conversion was defined as any unplanned transition from robotic to open surgery after initiation of the robotic procedure. Reasons for conversion were assigned using a hierarchical, mutually exclusive framework: intraoperative complication, patient instability, vascular involvement, or strategic surgeon decision. Results: Among 311 patients, 36 (11.6%) required conversion to laparotomy. The most common recorded reason was strategic surgeon decision (n = 18, 50.0%), followed by vascular involvement (n = 10, 27.8%), intraoperative complications, and patient instability. On multivariable analysis, independent predictors of conversion were preoperative biliary drainage (OR 7.36; p = 0.021) and vascular involvement (OR 22.22; p = 0.027), while male sex was protective (OR 0.22; p = 0.032). Robotic experience > 20 cases was associated with reduced conversion risk in an adjusted model (aOR 0.17; p = 0.027). Conversion was associated with longer hospital stay, higher 30-day and 90-day mortality, and increased postoperative complications. Clinically relevant postoperative pancreatic fistula rates were similar between groups overall. Conclusions: In elderly and/or obese surgically high-risk patients selected for attempted RPD, conversion occurred in approximately one in nine cases and was associated with worse short-term outcomes. These findings support careful patient selection, recognition of vascular complexity, transparent counseling, and a low threshold for strategic conversion in expert robotic pancreatic programs. Conversion should not be interpreted uniformly as operative failure, because its implications differ according to mechanism and timing.
Conversion to open surgery during robotic pancreatoduodenectomy in surgical high-risk groups: patterns, risk factors, and outcomes in elderly and/or obese patients / Marchese, T., Valle, V., Ielpo, B., Comandatore, A., Di Franco, G., Salvia, R., Ross, S., Martinie, J.B., Wray, C.J., Spampinato, M.G., Pakataridis, P., Giulianotti, P.C., Morelli, L., Null, N., Pastena, M., Esposito, A., Burdío, F., Sanchez-Velázquez, P., D'Hondt, M., Willems, E., et al.. - In: SURGICAL ENDOSCOPY. - ISSN 0930-2794. - (2026). [10.1007/s00464-026-13063-2]
Conversion to open surgery during robotic pancreatoduodenectomy in surgical high-risk groups: patterns, risk factors, and outcomes in elderly and/or obese patients
Perra, TeresaMembro del Collaboration Group
;Porcu, AlbertoMembro del Collaboration Group
;
2026-01-01
Abstract
Background: Conversion to laparotomy during robotic pancreatoduodenectomy (RPD) carries important clinical implications, yet its incidence, predictors, and consequences in elderly and/or obese patients remain poorly characterized. This study aimed to define the conversion rate, identify preoperative predictors, and assess the impact of conversion on postoperative outcomes in elderly and/or obese surgically high-risk patients undergoing attempted RPD. Methods: A retrospective analysis was performed using a multi-institutional database. Patients were included if they underwent attempted RPD and met at least one high-risk criterion: age ≥ 80 years and/or BMI ≥ 30 kg/m2. Conversion was defined as any unplanned transition from robotic to open surgery after initiation of the robotic procedure. Reasons for conversion were assigned using a hierarchical, mutually exclusive framework: intraoperative complication, patient instability, vascular involvement, or strategic surgeon decision. Results: Among 311 patients, 36 (11.6%) required conversion to laparotomy. The most common recorded reason was strategic surgeon decision (n = 18, 50.0%), followed by vascular involvement (n = 10, 27.8%), intraoperative complications, and patient instability. On multivariable analysis, independent predictors of conversion were preoperative biliary drainage (OR 7.36; p = 0.021) and vascular involvement (OR 22.22; p = 0.027), while male sex was protective (OR 0.22; p = 0.032). Robotic experience > 20 cases was associated with reduced conversion risk in an adjusted model (aOR 0.17; p = 0.027). Conversion was associated with longer hospital stay, higher 30-day and 90-day mortality, and increased postoperative complications. Clinically relevant postoperative pancreatic fistula rates were similar between groups overall. Conclusions: In elderly and/or obese surgically high-risk patients selected for attempted RPD, conversion occurred in approximately one in nine cases and was associated with worse short-term outcomes. These findings support careful patient selection, recognition of vascular complexity, transparent counseling, and a low threshold for strategic conversion in expert robotic pancreatic programs. Conversion should not be interpreted uniformly as operative failure, because its implications differ according to mechanism and timing.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
