The breaking point in robotic pancreaticoduodenectomy: factors influencing conversion thresholds and early postoperative outcomes in a tertiary referral center

Abstract Background Robotic pancreaticoduodenectomy (RPD) has expanded the indications of minimally invasive pancreatic surgery. However, conversion to open surgery remains a relevant intraoperative event, and data on its determinants and clinical impact in real-world robotic programs are limited. Conversion is increasingly regarded as a safety-driven decision rather than a technical failure, particularly in experienced centers. Methods This retrospective single-center cohort study included all consecutive adult patients undergoing intended RPD between April 2018 and October 2025. Conversion was defined as any unplanned laparotomy after initiation of the robotic approach. Patient-, disease-, and procedure-related variables were analyzed. Factors associated with conversion were explored using univariable analyses and multivariable Firth penalized logistic regression. Postoperative outcomes were assessed descriptively according to conversion status using effect size measures. Results Among 130 patients undergoing RPD, 16 (12.3%) required conversion. On multivariable analysis, vascular contact requiring resection emerged as the strongest factor associated with conversion, followed by periampullary tumor location, while previous pancreatitis showed a borderline association. Most conversions occurred early in the procedure (75%) and were strategic rather than urgent (87.5%). Conversion was associated with higher intraoperative transfusion rates and increased postoperative resource utilization, including longer hospital and high-dependency unit stay. No clear evidence of a large increase in major postoperative morbidity was observed, and rates of major postoperative complications, pancreatic fistula (grade B/C), and 30-day mortality were similar between groups, although estimates remain imprecise due to the limited number of converted cases. Conclusions In a high-volume robotic pancreatic program, conversion during RPD was primarily driven by anatomical and disease-related complexity rather than surgical inexperience. When performed in a timely and controlled manner, conversion may represent a proactive safety strategy rather than a technical failure, although these findings should be interpreted cautiously given the limited number of conversion events. Graphical Abstract