Risk of Open Conversion During Robotic Gastrectomy for Gastric Cancer: Optimizing Patient Selection

Abstract

BACKGROUND AND OBJECTIVES: Robotic surgery for gastric adenocarcinoma (GC) shows recovery benefits compared to open and laparoscopic approaches. While open conversion (OC) is associated with poorer outcomes, factors influencing robotic gastrectomy (RG) OC are obscure. We identified preoperative and intraoperative risk factors for OC and associated outcomes. METHODS: We performed a retrospective analysis of RG using a prospectively maintained GC database from a high-volume comprehensive US cancer center between January 2010 and October 2022. RG standardization began in July 2015, with ongoing expansion of patient selection criteria. Patients who underwent radical resection with biopsy-proved GC were included in the analysis if the operation was initiated robotically. Preoperative documentation of likely to convert to open procedures was identified. RESULTS: Of 289 gastrectomy cases, 133 (46.0%) were RG. Before RG standardization, OC rate was 42.1% (n = 8/19); then decreased to 15.8% (n = 18/114). Factors causing unplanned OC included instability upon insufflation (7.7%), difficult esophagojejunostomy (23.1%), bulky nodes (26.9%), and tumor invasion/fibrosis (38.5%). On multivariate analysis, Preoperative EUS (OR 0.78) decreased OC likelihood, whereas prior abdominal surgeries (OR 1.31) increased OC likelihood (p < 0.05). D2 lymphadenectomy and neoadjuvant treatment did not increase OC likelihood. CONCLUSIONS: Pre-operatively identifiable OC factors can guide RG patient selection. Yet, certain intraoperative findings challenge RG and require improved preoperative planning.