title: Robotic hepatobiliary and pancreatic surgery: lessons learned and predictors for conversion.
abstract: BACKGROUND
  The use of surgical robots has slowly gained an increasing presence in the realm of hepatobiliary and pancreatic (HPB) surgery. With additional experience, anecdotal evidence has been useful in guiding patient selection for complex robotic procedures. In the following analysis, we reviewed our case series and looked for predictors of conversion in robotic HPB surgery.
  
  
  METHODS
  We retrospectively reviewed all patients who underwent robotic HPB procedures by a single surgeon at two institutions during March 2006-June 2012. Patient demographics, operative data, procedure type and conversion information were recorded. Trends were analysed for indications for conversion. A subset analysis of robotic-assisted laparoscopic distal pancreatomy was performed and compared with laparoscopic and open distal pancreatectomy during the same time period by the same surgeon.
  
  
  RESULTS
  During this time period, 77 patients underwent robotic hepatobiliary and pancreatic procedures. All procedures were performed by a single surgeon (J.M.) and included 38 males (49%) and 39 females (51%). Median age was 59 and the majority of patients were ASA class III. There were 24 conversions, which decreased in frequency from 2009 (7) to 2011 (3). Reasons for conversion included significant obesity and technical difficulty. Patients with conversions had more intraoperative blood loss (966 vs 176 ml), more frequently received transfusion (29% vs 2%) and were more likely to have postoperative intensive care. Overall length of stay was longer following conversion (8.3 vs 5.6 days).
  
  
  CONCLUSIONS
  Robotic-assisted hepatobiliary and pancreatic procedures are often extremely complex, with a significant learning curve. Recognizing factors that prohibit successful completion of a robotic-assisted surgical procedure is key for patient safety. Careful patient selection in the appropriate settings facilitates the maximal benefit of robotic-assisted complex HPB surgery.
authors.affiliation: Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Charlotte, NC, USA.
authors.forename: Erin M
authors.initials: EM
authors.lastname: Hanna
authors.forename: Nigel
authors.initials: N
authors.lastname: Rozario
authors.forename: Christopher
authors.initials: C
authors.lastname: Rupp
authors.forename: David
authors.initials: D
authors.lastname: Sindram
authors.forename: David A
authors.initials: DA
authors.lastname: Iannitti
authors.forename: John B
authors.initials: JB
authors.lastname: Martinie
mesh_terms: D001662:Biliary Tract Surgical Procedures / Q000706:statistics & numerical data*; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D005260:Female; D006498:Hepatectomy / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009657:North Carolina / Q000453:epidemiology; D010180:Pancreatectomy / Q000706:statistics & numerical data*; D015995:Prevalence; D012307:Risk Factors; D012371:Robotics / Q000706:statistics & numerical data*; D025321:Surgery, Computer-Assisted / Q000706:statistics & numerical data*; D016896:Treatment Outcome