Robotic Pancreatoduodenectomy Carries Greater Risk of Morbidity after Conversion than Laparoscopy

Objective: To compare postoperative outcome following conversion in robotic (RPD) versus laparoscopic (LPD) pancreatoduodenectomy. Summary background data: Minimally invasive pancreatoduodenectomy (MIPD) is increasingly performed using RPD or LPD. Conversion to open surgery is a risk factor for postoperative morbidity, and its impact may vary by surgical approach. Methods: Retrospective, propensity-score matched multicenter cohort from the E-MIPS registry across 75 European centers (January 2019-2024). Patients undergoing conversion during RPD or LPD were matched 1:1. Outcomes were also analyzed by conversion type (pre-emptive vs urgent). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3). Secondary outcomes included pancreas-specific complications, length of stay, and Ideal Outcome (no mortality, major morbidity, POPF B/C, reoperation, prolonged stay, or readmission). Centers were stratified as low- (<20 MIPD/year) or high-volume (≥20/year). Results: Of 2201 MIPD patients, 269 (12%) required conversion, with no difference between RPD (181/1568, 12%) and LPD (88/633, 14%; P=0.13). After matching (88 RPD vs. 88 LPD), RPD conversion was associated with higher major morbidity (49% vs. 31%; P=0.021), especially in pre-emptive conversion (47% vs. 30%; P=0.043). In high-volume centers, major morbidity (48.4% vs 29.4%) and POPF grade B/C was more frequent in RPD than LPD (24% vs. 8%; P=0.019). Blood loss was greater in RPD overall and in both pre-emptive and urgent conversions (all P < 0.01). Conclusions: Despite comparable conversion rates, RPD conversion was associated with higher morbidity. Structured decision-making protocols and robotic team training regarding conversion are warranted.