Conversion in Minimally Invasive Liver Surgery: The Impact of Conversion Urgency and Surgical Approach

Gabriela Pilz da Cunha; Davit Aghayan; Federica Cipriani; Darren W Chua; Victoria Morrison-Jones; Jacopo Lanari; Celine de Meyere; Kongyuan Wei; Stylianos Tzedakis; John Martinie; Daniel Osei Bordom; Soufyan El Adel; Kaitlyn Crespo; Paolo Magistri; Nadia Russolillo; Simone Conci; Andrea Benedetti Cacciaguerra; Daniel D'Souza; Gabriel Zozaya; Cèlia Caula; Shafiq Rehman; Åsmund Avdem Fretland; Ye-Xin Koh; Marc G Besselinkz; Susan van Dieren; David Geller; Ricardo Robles Campos; Roland S Croner; Elio Jovine; Mikhail Efanov; Adnan Alseidi; Riccardo Memeo; Ibrahim Dagher; Felice Giuliante; Ernesto Sparrelid; Jawad Ahmad; Tom Gallagher; Moritz Schmelzle; Steven White; Santi Lopez Ben; Fernando Rotellar; Pablo E Serrano; Marco Vivarelli; Andrea Ruzzenente; Alessandro Ferrero; Fabrizio Di Benedetto; Iswanto Sucandy; Robert P Sutcliffe; Dionisios Vrochides; David Fuks; Rong Liu; Mathieu D'Hondt; Umberto Cillo; John N Primrose; Brian K P Goh; Francesca Ratti; Bjørn Edwin; Mohammad Abu Hilal; Rutger-Jan Swijnenburg; International Consortium on Minimally Invasive Liver Surgery (IMILS)

doi:10.1245/s10434-026-19124-z

Conversion in Minimally Invasive Liver Surgery: The Impact of Conversion Urgency and Surgical Approach

Ann Surg Oncol. 2026 Mar 16. doi: 10.1245/s10434-026-19124-z. Online ahead of print.

Authors

Gabriela Pilz da Cunha^{1

2}, Davit Aghayan^{3

4

5}, Federica Cipriani⁶, Darren W Chua⁷, Victoria Morrison-Jones⁸, Jacopo Lanari⁹, Celine de Meyere¹⁰, Kongyuan Wei¹¹, Stylianos Tzedakis¹², John Martinie¹³, Daniel Osei Bordom¹⁴, Soufyan El Adel^{1

2

4}, Kaitlyn Crespo¹⁵, Paolo Magistri¹⁶, Nadia Russolillo¹⁷, Simone Conci¹⁸, Andrea Benedetti Cacciaguerra¹⁹, Daniel D'Souza²⁰, Gabriel Zozaya²¹, Cèlia Caula²², Shafiq Rehman²³, Åsmund Avdem Fretland³, Ye-Xin Koh⁷, Marc G Besselinkz^{1

2}, Susan van Dieren¹, David Geller²⁴, Ricardo Robles Campos²⁵, Roland S Croner²⁶, Elio Jovine²⁷, Mikhail Efanov²⁸, Adnan Alseidi^{29

30}, Riccardo Memeo³¹, Ibrahim Dagher³², Felice Giuliante³³, Ernesto Sparrelid³⁴, Jawad Ahmad³⁵, Tom Gallagher³⁶, Moritz Schmelzle³⁷, Steven White²³, Santi Lopez Ben²², Fernando Rotellar²¹, Pablo E Serrano²⁰, Marco Vivarelli¹⁹, Andrea Ruzzenente¹⁸, Alessandro Ferrero¹⁷, Fabrizio Di Benedetto¹⁶, Iswanto Sucandy¹⁵, Robert P Sutcliffe¹⁴, Dionisios Vrochides³⁸, David Fuks³⁹, Rong Liu⁴⁰, Mathieu D'Hondt¹⁰, Umberto Cillo⁹, John N Primrose⁸, Brian K P Goh^{7

41}, Francesca Ratti⁶, Bjørn Edwin³, Mohammad Abu Hilal^#^{42

43}, Rutger-Jan Swijnenburg^#^{44

45}; International Consortium on Minimally Invasive Liver Surgery (IMILS)

Affiliations

¹ Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
² Cancer Center Amsterdam, Amsterdam, The Netherlands.
³ The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway.
⁴ Department of Surgery, Vestre Viken Hospital Trust, Ringerike Hospital, Hønefoss, Norway.
⁵ Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.
⁶ Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.
⁷ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore, Singapore.
⁸ Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
⁹ Department of Surgical, Oncological and Gastroenterological Sciences, General Surgery 2, Hepatopancreatobiliary Surgery and Liver Transplantation, Padua University Hospital, Padua, Italy.
¹⁰ Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
¹¹ Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
¹² Department of Hepatobiliary, Digestive and Endocrine Surgery, Cochin hospital, AP-HP, Université Paris Cité, Inria, Inserm, HeKA, Paris, France.
¹³ Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
¹⁴ Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
¹⁵ Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
¹⁶ Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
¹⁷ Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy.
¹⁸ Department of Surgery, University of Verona, Verona, Italy.
¹⁹ Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy.
²⁰ Department of Surgery, McMaster University, Hamilton, ON, Canada.
²¹ HPB and Liver Transplantation Unit, Department of Surgery, University Clinic, Universidad de Navarra, Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.
²² Servei de Cirurgia General i Digestiva, Hospital Doctor Josep Trueta de Girona, Girona, Catalonia, Spain.
²³ Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
²⁴ Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²⁵ Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain.
²⁶ Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany.
²⁷ Department of Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
²⁸ Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
²⁹ Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
³⁰ Departmesnt of Surgery, University of California, San Francisco, CA, USA.
³¹ Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy.
³² Department of Hepatobiliary, Digestive and Endocrine Surgery, Cochin Hospital, Université Paris Cité, Paris, France.
³³ Hepato-Biliary Surgery Unit, Fondazione Policlinico Universitario A.Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
³⁴ Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
³⁵ University Hospitals Coventry and Warwickshire, Coventry, UK.
³⁶ St. Vincent's University Hospital, Dublin, Ireland.
³⁷ Hannover Medical School, Department of General, Visceral and Transplant Surgery, Hannover, Germany.
³⁸ Division of Abdominal Transplantation, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
³⁹ Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France.
⁴⁰ Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
⁴¹ Duke-National University of Singapore Medical School, Singapore, Singapore.
⁴² Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK. abuhilal9@gmail.com.
⁴³ Department of Surgery, School of Medicine, The University of Jordan, Amman, Jordan. abuhilal9@gmail.com.
⁴⁴ Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands. r.j.swijnenburg@amsterdamumc.nl.
⁴⁵ Cancer Center Amsterdam, Amsterdam, The Netherlands. r.j.swijnenburg@amsterdamumc.nl.

^# Contributed equally.

PMID: 41838359
DOI: 10.1245/s10434-026-19124-z

Abstract

Background: Conversion to open surgery forfeits any potential benefits of minimally invasive liver surgery (MILS), however, it remains uncertain whether the conversion itself introduces additional risk. The impact may differ depending on urgency (emergency or elective) and surgical approach (robotic or laparoscopic liver resection). This study aimed to evaluate outcomes of emergency and elective conversions in robotic liver resection (RLR) and laparoscopic liver resection (LLR).

Patients and methods: Data from 34 international centers of patients undergoing converted MILS procedures (stratified for conversion urgency) were retrospectively compared with patients who underwent elective open liver surgery using propensity score matching. Additionally, RLR and LLR conversions were compared. Conversion risk factors were identified using multivariable logistic regression in RLR and LLR separately.

Results: Among 10,548 MILS procedures (n = 1626 RLR and n = 8922 LLR), 719 (6.8%) were converted. Both emergency (n = 226) and elective (n = 472) conversions were associated with longer operative time and more Pringle use compared with open surgery. Emergency conversions additionally showed higher blood loss, transfusion rates, severe morbidity, and even mortality. Matched analysis of 40 pairs of RLR and LLR conversions identified no significant differences in perioperative outcomes, although mortality following RLR conversion was remarkably high (7.7%). RLR conversion risk factors were bilobar disease and anatomically major resection; whereas LLR risk factors included cirrhosis, history of previous liver surgery, tumor size, technically complex, and anatomically major resection.

Conclusions: Emergency conversions in MILS are associated with worse outcomes, whereas elective conversions appear safe, highlighting the importance of timely, controlled conversion. Further investigation into the safety of robotic conversions is warranted.

Keywords: Conversion; Hepatectomy; Laparoscopic liver surgery; Minimally invasive liver surgery; Robotic liver surgery.