Emergency Conversion Preparedness Is Paramount in Robotic Thoracic Surgery

Robotic-assisted surgery has ushered in a new era in thoracic surgery, offering enhanced precision, improved ergonomics, better visualization, and digital tools aimed at facilitating surgeon training and patient outcomes. 

Minimally invasive thoracic surgery carries the potential for emergency conversion to open thoracotomy. Despite its advantages, emergency conversion during robotic-assisted thoracic surgery (RATS) has the unique challenge of the surgeon being positioned away from the patient's bedside.

While infrequent, these conversions are high-stakes events that demand meticulous preparation and execution. Our group at Lahey Hospital & Medical Center in Burlington, Massachusetts, has developed a reliable and effective technique that was featured in an article published earlier this year in Operative Techniques in Thoracic and Cardiovascular Surgery.¹ 

In this viewpoint article, we highlight key considerations every surgeon should be aware of based on insights from our experience regarding emergency conversions during RATS.

Understanding Emergency Conversions

Emergency conversion refers to an unplanned shift from a minimally invasive to an open surgical approach in response to intraoperative complications that cannot be safely managed thoracoscopically. Unlike elective or strategic conversions, which are anticipated and made preemptively due to anatomical or oncologic considerations, emergency conversions are reactive, often triggered by major bleeding, complex anatomy, or loss of visualization. Although the overall conversion rate is lower with RATS compared to video-assisted thoracoscopic surgery (VATS), emergency conversions present greater technical and logistic challenges in RATS.²

Prevalence and Predictors

A large study on conversions from The Society of Thoracic Surgeons showed that while emergency conversions during minimally invasive lobectomy are relatively infrequent, they are clinically significant.² The overall conversion rate was 11.0% for VATS and 6.0% for RATS, with emergency events accounting for the majority of conversions.

Several patient and surgical factors were identified as predictors of emergency conversion. The most consistent risk factors included reduced forced expiratory volume in 1 second, left-sided resections, and advanced clinical stage, particularly stage III disease. In VATS, additional predictors included elevated body mass index, male sex, hypertension, and prior chemotherapy. Conversely, emergency conversions in RATS were more frequently triggered by vascular injuries and were associated with diabetes and lower institutional case volume.²

Preoperative Planning and Intraoperative Decision-Making

Operating Room and Surgeon Considerations

Effective management of emergency conversion begins well before the first incision and continues through every phase of the operation. Thorough preparation and clear communication are essential to ensuring patient safety and optimizing outcomes.^3,4 

Preparation starts with a comprehensive team briefing, during which anticipated risks are discussed, and a detailed conversion plan is reviewed. This approach includes clearly marking the planned thoracotomy incision site to guide a rapid transition if needed. Teams also should rehearse the conversion protocol through simulation training, particularly in institutions where bedside assistant experience may vary.

Optimizing patient setup is equally critical. The robotic boom should be fully extended during docking to maximize workspace and facilitate swift undocking if conversion is required. Additionally, essential equipment for conversion to open should be readily available.

The decision to convert should be proactive, not reactive. Delayed conversion can lead to increased blood loss, longer operative times, and higher complication rates.^1-5 Predefined intraoperative protocols and clear team communication enable timely, coordinated responses. Incorporating a conversion plan into preoperative briefings, especially for high-risk cases, is essential for maintaining control during unexpected events.

Patient Considerations

Emergency conversion should be part of the preoperative discussion with patients. Understanding that conversions may occur, and that they are sometimes the safest course of action, can help preserve trust and mitigate dissatisfaction in the event of unexpected changes.

Technical Considerations

A smooth and controlled transition from robotic to open surgery hinges on timely decision-making and technical precision. Once the need for conversion is recognized, the surgeon should apply pressure to the bleeding site using robotic instruments, while clearly announcing the conversion to the team.

As maintaining visualization is critical, the robotic camera should remain in place until thoracotomy access is established. A limited thoracotomy is performed at the pre-marked site, allowing the bedside assistant to insert a sponge stick for direct pressure at the hilum (see Figure). Tamponade is then transitioned from robotic control to manual control by the assistant, after which the surgeon scrubs in and joins at the bedside. The robot is undocked with trocars left in place, and the thoracotomy is extended to achieve definitive exposure and bleeding control.

In settings where a qualified assistant is not available, the console surgeon may maintain pressure with the posterior robotic arm before leaving the console to perform the thoracotomy. This sequence ensures continuous control of the operative field and minimizes disruption during a critical intraoperative event (see Table). Two common challenges can complicate this process: loss of visualization and workspace limitations. Removing the robotic camera too early can result in dangerous lapses in visual control, making a backup thoracoscopic scope essential. Additionally, inadequate undocking or poor positioning of the robotic boom can obstruct access during conversion. Anticipation and preparation are key in these scenarios.

Outcomes and Impact

Emergency conversion during RATS is associated with increased operative time, greater blood loss, higher transfusion requirements, and elevated rates of postoperative complications, such as arrhythmias and prolonged chest tube duration.⁵ These patients also tend to experience longer hospital stays.

However, when performed promptly and effectively, emergency conversion does not lead to increased mortality and should not be viewed as a failure.⁵ Rather, it is a proactive and lifesaving intervention that mitigates the risk of more severe adverse events. Importantly, while short-term morbidity is higher, long-term survival among patients who undergo emergency conversion is comparable to those whose surgeries are completed robotically, underscoring the importance of timely surgical judgment and execution.

Emergency conversion during robotic thoracic surgery, while uncommon, is a pivotal competency for all surgeons. A structured, team-based response, grounded in simulation and preparation, can mitigate morbidity. Recognizing risk factors and preparation through simulation ensures that these high-risk events are managed with confidence and competence.

Disclaimer

The thoughts and opinions expressed in this column are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Elliot Servais is chief of the Section of Thoracic Surgery in the Division of Thoracic and Cardiovascular Surgery and chair of the Robotic Surgery Committee at Lahey Hospital & Medical Center in Burlington, MA. He also is an associate professor of surgery at UMass Chan Medical School in Worcester, MA.

References

1. Watkins AA, Ricard C, Hoagland D, Shehata D, et al. Emergency conversion from robotic thoracoscopy to thoracotomy: A safe, reproducible, and effective technique. Oper Tech Thorac Cardiovasc Surg. 2025;30(1):67-74.
2. Servais EL, Miller DL, Thibault D, et al. Conversion to thoracotomy during thoracoscopic vs robotic lobectomy: Predictors and outcomes. Ann Thorac Surg. 2022;114(2):409-417.
3. Agzarian J, Shargall Y. Open thoracic surgery: Video-assisted thoracoscopic surgery (VATS) conversion to thoracotomy. Shanghai Chest. 2017;1:31.
4. Stahel PF, Cobianchi L, Dal Mas F, et al. The role of teamwork and nontechnical skills for improving emergency surgical outcomes: An international perspective. Patient Saf Surg. 2022;16(1):8.
5. Herrera LJ, Schumacher LY, Hartwig MG, et al. Pulmonary open, robotic, and thoracoscopic lobectomy study: Outcomes and risk factors of conversion during minimally invasive lobectomy. J Thorac Cardiovasc Surg. 2023;166(1):251-262.