Robotic converts: does everyone see the light?
For many hepatobiliary surgeons and trainees, their first foray into minimally invasive hepato-pancreato-biliary (HPB) surgery is with left-sided pancreatic resections. These are generally for small, non-invasive lesions, and the absence of a reconstruction phase eliminates the technical complexity and steep learning curve of other case types. Patients recover quickly, and emboldened by such outcomes, more advanced cases begin populating the booking queue. What happens, though, when the ascendant robotic HPB surgeon overplays their hand and finds themselves amid an open conversion?
In “Conversion of robotic distal pancreatectomy: predictors and outcomes in an international multicenter study”, Müller et al. describe the robotic distal pancreatectomy experience of a multicenter, international consortium (1). Studying over 2,400 cases, the authors report a 3.1% conversion rate for left-sided pancreatic resections with predictable metrics such as higher body mass index (BMI), prior abdominal surgery, and larger lesions contributing to either planned or emergent open conversion. Unsurprisingly, these operations took longer and had higher intraoperative blood loss. Notably, however, the small percentage of converted patients suffered disproportionately worse outcomes in all measured areas—doubled mortality and major complication rates, quintupling rate of reintervention, and a dramatic reduction in the extent of lymph node harvest. Albeit a small percentage, these findings suggest that converted left-sided pancreatectomies represent a vastly different clinical entity than the so-called “chip shot distal”.
This paper highlights a prevalent but unspoken misconception about distal pancreatectomy and the utility of the robotic approach. While most left-sided pancreatic lesions can and should be approached robotically, sufficient provider experience and careful patient selection remain paramount. Specifically, surgeons must consider several clinical and anatomic factors before arriving at the decision on the optimal approach. First, how medial is the lesion? If a subtotal or near-subtotal distal pancreatectomy is required, the surgeon must recognize that this is an entirely different operation compared to a small lesion dangling off the pancreatic tail. Second, what is the proximity of the lesion to the splenic vessels, and what should be done with the spleen? Accumulating evidence suggests a benefit to splenic preservation beyond patient preference, and a firm grasp of both Warshaw and Kimura splenic salvage techniques is key. In unaccustomed robotic hands, however, these can be prohibitively dangerous. Third, are there signs of more advanced disease for which achieving oncologic radicality may jeopardize the safety of the planned approach? Although beneficial to the patient from a recovery standpoint, a robotic radical antegrade modular pancreatosplenectomy (RAMPS procedure) early in a surgeon’s learning curve should be weighed carefully.
Technical inexperience paired with an unbridled mindset can quickly lead to a catastrophic intraoperative situation. While this paper supports the use of robotics for left-sided pancreatic resections (recall that textbook outcomes were achieved in 74% of robotic distal pancreatectomies), it reinforces a timeless, cautionary tale—when things go south, they go south fast. To ensure safe and sound HPB surgery as the field advances its use minimally invasive approach, providers are reminded to balance their own limitations with careful patient selection.
Acknowledgments
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Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article has undergone external peer review.
Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-534/prf
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Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-534/coif). The authors have no conflicts of interest to declare.
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References
- 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. [Crossref]
