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Page 187 Body et al. Art Int Surg 2022;2:186-94 https://dx.doi.org/10.20517/ais.2022.28

[1]
surgery and the benefit of smaller incisions has resulted in MIS becoming the standard approach for many
[2,3]
operations . In several surgical specialities, such as colorectal and bariatrics, most procedures are
performed using an MIS technique. MIS has not yet been widely embraced in hepato-pancreato-biliary
(HPB) surgery, specifically pancreatic surgery. This is largely because of the nature of complex resections,
proximity to major vessels requiring precise tissue dissection and small calibre lumen anastomoses that
[4-6]
make a laparoscopic approach technically difficult . There is a considerable learning curve for
laparoscopic pancreatoduodenectomy (LPD); in a study, researchers reported that 104 procedures are
required before proficiency is achieved .
[7]
The delay in the uptake of pancreatic MIS is also partly because of perceived poor outcomes. In several
studies, researchers have shown an increase in 30-day mortality with LPD [8-10] , which is thought to be
because of low-volume complex procedures and the absence of an adequate surgical training
programme [8-11] .

Robotic surgery, the next generation of MIS, has overcome many of the technical limitations of
laparoscopy [12-16] . The advances include a high-resolution three-dimensional (3D) camera and articulated
instruments that have seven degrees of motion and eliminate physiological tremors. The resulting increased
dexterity and improvement in hand-eye coordination enhance surgical precision. This has led surgeons to
perform operations that were traditionally not amenable to, or difficult to perform with, minimal access
techniques [17,18] . The first robotic pancreatoduodenectomy (RPD) was performed by Giulianotti in 2003
[19]
and there are now several studies in which researchers have reported robotic surgery to be beneficial for
technically complex procedures [12-16] . Furthermore, there is increasing evidence that robotic pancreatic
resections, in trained and experienced hands, are feasible and safe, with morbidity, mortality and
oncological outcomes comparable to other surgical techniques [14,20,21] .

As robotic surgery is gaining momentum in other surgical specialities, an increasing number of hospitals
[22]
now have access to robotic theatres . From 2010 to 2017, there was an increase of 2360% in the number of
general surgical robotic operations in the US . In a recent study on trends in minimally invasive
[23]
pancreatoduodenectomy in the US, researchers showed that there was an overall decrease in the use of
conventional laparoscopy and an increase in the use of robotics over the last few years . In England, there
[24]
was a 410% increase in robotic surgery between 2013 and 2019 . Thus, the continued evolution of robotic
[25]
surgery is considered to be inevitable and there is now a strong drive for robotic pancreatic surgery to
expand.

Robotic surgery requires different technical skills from both open and laparoscopic surgery. New operative
conditions that need to be managed include the separation of the console surgeon from the operative field,
absence of direct perception of the position of surgical instruments outside the visual field and absence of
haptic feedback [26,27] . During early experiences with robotic pancreatic surgery, the loss of haptic feedback
was thought to potentially increase blood loss. However, it has since been shown that improved visual
feedback by magnified 3D vision offers greater visualisation and control of splenic vessels, which leads to
improved outcomes and a higher splenic preservation rate in robotic pancreatic surgery compared with
[26]
laparoscopic distal pancreatectomy [106/198 (53.6%) and 76/281 (27.0%), respectively; P < 0.0001] .
A significant drawback of robotic surgery has been the high cost, particularly associated with increased
perioperative costs, which are likely to deter centres in low-income countries. However, many centres have
shown reduced post-operative costs because of a shorter length of stay and improved post-operative
outcomes [28-30] . With the increasing use of robotic surgery, subsequent competition between robotic