The Breaking Point in Robotic Pancreaticoduodenectomy: Predictors of Conversion and Early Postoperative Impact in a Tertiary Referral Center

Background. Robotic pancreaticoduodenectomy (RPD) is increasingly performed in high-volume centers, yet conversion to open surgery remains a critical intraoperative event. Often perceived as a technical failure, conversion may instead represent a safety-driven strategy in complex cases. Data on its determinants and peri- and postoperative impact in mature robotic programs remain limited. Methods. This retrospective single-center cohort study included adult patients undergoing elective RPD between April 2018 and October 2025 at a tertiary referral center for pancreatic surgery. Variables associated with conversion at univariable analysis (p < 0.10) were entered into a multivariable logistic regression model, with statistical significance set at p < 0.05. Peri- and postoperative outcomes were compared between converted and non-converted cases. Results. During the study period, 130 patients underwent RPD, of whom 16 (12.3%) required conversion. On multivariable analysis, vascular contact requiring resection was the strongest factor independently associated with conversion (p < 0.001). Periampullary tumor location (p = 0.023) and previous pancreatitis (p = 0.008) were also independently associated with conversion. Converted cases were characterized by a significantly higher rate of intraoperative bleeding requiring transfusion. Overall and major postoperative complication rates, including clinically relevant postoperative pancreatic fistula and R0 resection rates, did not differ significantly between groups. Conversion was associated with longer hospital stay and prolonged high-dependency unit stay. Conclusions. In this tertiary-center experience, conversion during RPD was mainly driven by preoperatively identifiable anatomical and disease-related factors. When anticipated and performed in a controlled manner, conversion did not adversely affect major postoperative outcomes.