What factors are associated with robotic distal pancreatectomy conversion? - Editorial Commentary

Sep 29, 2026

Editorial commentary examining predictors of conversion in robotic distal pancreatectomy (RDP) and contextualizing them within laparoscopic distal pancreatectomy (LDP). The referenced international multicenter retrospective analysis of 2,452 RDPs reported 3.1% conversion to open surgery, with converted cases showing longer operative times, greater blood loss, and increased overall and major complications, including higher postoperative pancreatic fistula, delayed gastric emptying, and 90-day mortality. Conversion was linked to lesion size, BMI, prior abdominal surgery, benchmark deviations, and age over 62, emphasizing patient selection via difficulty scoring systems.

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Editorial Commentary

Conversion in robotic distal pancreatectomy: key predictors and outcomes

Background: laparoscopic distal pancreatectomy adoption and conversion rates

Robotic distal pancreatectomy evolution and rationale

Defining conversion and Brescia Guidelines

Conversion rates and preoperative factors in laparoscopic distal pancreatectomy

Editorial Commentary What factors are associated with robotic distal pancreatectomy conversion? Jose M. Ramia1,2,3^, Cándido Alcázar1,2,3^ 1Department of Surgery, University General Hospital Dr. Balmis, Alicante, Spain; 2Health and Biomedical Investigation Institute (ISABIAL), Alicante, Spain; 3Department of Pathology and Surgery, Miguel Hernandez University, Alicante, Spain Correspondence to: Jose M. Ramia, MD, PhD, FACS, FRCS, FRCS (Ed) . Department of Surgery, University General Hospital Dr. Balmis, Sol Naciente 8, 16D, Alicante 03016, Spain; Health and Biomedical Investigation Institute (ISABIAL), Alicante, Spain; Department of Pathology and Surgery, Miguel Hernandez University, Alicante, [Spain. Email: jose_ramia@hotmail.com](Spain. Email: jose_ramia@hotmail.com). Comment on: Müller PC, Sedlaczek P, Billeter AT, et al. Conversion of robotic distal pancreatectomy: predictors and outcomes in an international multicenter study. Ann Surg 2025. [Epub ahead of print] . doi: 10.1097/SLA.0000000000006821 . Keywords: Distal pancreatectomy; conversion; surgery; robot; pancreas Submitted Sep 23, 2025. Accepted for publication Nov 18, 2025. Published online Dec 24, 2025. doi: 10.21037/gs-2025-438 View this article at: [https://dx.doi.org/10.21037/gs-2025-438](https://dx.doi.org/10.21037/gs-2025-438) We would like to comment the excellent manuscript by Müller et al. (1), titled “Conversion of robotic distal pancreatectomy: predictors and outcomes in an international multicenter study”, which was published in the prestigious Q1 journal, Annals of Surgery. This is the first major series dedicated to robotic distal pancreatectomies (RDPs) conversion. This retrospective multicenter study examined 2,452 RDPs performed at 16 international centers, of which 75 (3.1%) required conversion to open surgery. In the cases of converted RDPs, the findings revealed that operative time was longer, blood loss was greater, and patients encountered more overall complications as well as major complications. Additionally, they experienced a higher incidence of postoperative pancreatic fistula, delayed gastric emptying, and a greater 90-day mortality rate. The multivariable analysis indicated that several factors were associated with conversion, including lesion size, body mass index (BMI), previous abdominal surgery, patients outside benchmark criteria, and age (>62 years old) . The authors emphasized the necessity of proper patient selection through validated difficulty scoring system (DSS) . The laparoscopic approach represented a significant advancement in abdominal surgery by the late 20th century. While there is no definitive agreement on the exact date of the first laparoscopic distal pancreatectomy (LPD), the most accepted year is 1992. Despite this, the widespread adoption of LPD encountered delays due to the complex anatomy of the pancreas, its proximity to major blood vessels, and the technical challenges associated with the procedure. Although the rates of LPD have been increasing, the growth has been gradual, but now is considered the gold standard (1) . But recent studies from various countries over the past 2 years indicate that the current rate of LPD ranges only from 40% to 70%(2) . In 2013, surgeons at the Mayo Clinic performed the first spleen-saving, vessel-preserving RDP using the da Vinci® surgical system. The robotic technique enhances visualization, minimizes tremor, and improves maneuverability during dissection (3) . In the past decade, RDP has gained popularity due advantageous learning curve and theoretical lower conversion rates compared to the laparoscopic approach. An international study conducted across 19 European countries compared LDP with RDP and found no significant differences in outcomes between matched patients, although RDP was associated with a longer operative time (4) . Some authors argue that nowadays RDP should be the standard procedure forresecting pancreatic tumors located in the body

FAQs

What is meant by “conversion” in minimally invasive pancreatic surgery?

Conversion generally refers to performing an unplanned laparotomy to complete the procedure. The Brescia Guidelines define it as an unplanned open incision, excluding specimen-extraction incision, and distinguish planned versus emergency conversions.

Which factors were associated with conversion in robotic distal pancreatectomy?

Multivariable analysis linked conversion to lesion size, BMI, previous abdominal surgery, patients outside benchmark criteria, and age greater than 62 years.

How did outcomes differ between non-converted and converted robotic distal pancreatectomy cases?

Converted cases had longer operative time, greater blood loss, and more overall and major complications, with higher rates of postoperative pancreatic fistula, delayed gastric emptying, and 90-day mortality.

Sep 29, 2026

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