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Shannon et al. Mini-invasive Surg 2023;7:32 https://dx.doi.org/10.20517/2574-1225.2023.83 Page 5 of 15

minimally invasive on post-operative pancreatic fistula.

Most of these studies included only patients with PDAC. When comparing minimally invasive to open DP
in patients with nonfunctioning pancreatic neuroendocrine tumors (PNET) specifically, long-term survival
did not differ; however, a minimally invasive approach did result in significantly fewer lymph nodes
harvested . Another study retrospective cohort study utilizing propensity score-matching to compare
[47]
minimally invasive and open DP for the treatment of PNET found less blood loss, complications, LOS, and
five-year recurrence in the minimally invasive group . Similar findings were seen in another multicenter
[48]
[49]
comparative study; however, cost was listed as the major limitation of a robotic approach .
Another area of the intense study is comparing robotic vs. traditional laparoscopic approaches to DP. One
of the first meta-analyses on the subject showed no difference in oncologic outcomes between the two
[50]
methods, although robotic DP had longer operative times and increased 90-day readmission rates .
Another recent multi-institutional trial showed some benefits to robotic DP in terms of decreased rates of
conversion to open, increased splenic preservation, and decreased readmission rates; however, it again
showed longer operative time compared to laparoscopic DP . A recent study by the European Consortium
[51]
on Minimally invasive Pancreatic Surgery concluded robotic and laparoscopic DP provide comparable R0
resection rates and overall survival, but a robotic approach was associated with longer operative time .
[52]
These collective findings may indicate that operative times may be related to the platform itself and the
learning curve of this approach .
[53]

Other techniques for minimally invasive DP have been studied, including the radical antegrade modular
pancreatosplenectomy (RAMPS) approach. DP was traditionally done via a left-to-right surgical approach
in which the spleen, tail, and body of the pancreas were fully mobilized, and then the pancreas was
[54]
divided . The RAMPS procedure has recently been popularized as an alternative to the traditional left-to-
right approach. First reported in 2003 by Strasberg et al., the RAMPS procedure involves dissection
performed from right to left, with an early division of the pancreatic parenchyma and splenic vasculature .
[55]
By performing dissection in an antegrade fashion, the RAMPS procedures allow for improved visibility and
procurement of lymph nodes, easier identification of superior mesenteric artery involvement, and
achievement of negative margins compared to traditional left-to-right approaches [56,57] . Importantly, there
was no increased risk of perioperative complication between the two techniques and even higher overall
survival in patients treated with RAMPS [58-60] .

With regards to a minimally invasive RAMPS, a recent systematic review evaluating laparoscopic RAMPS
reported median R0 resection rates between 91%-100% and concluded laparoscopic RAMPS had acceptable
oncologic outcomes and safety profile . In comparison to an open approach, Zhang et al. subsequently
[61]
performed a single-center retrospective study, which showed that laparoscopic RAMPS was safe and had
equivalent oncologic outcomes . Similarly, multiple recent meta-analyses have shown no differences in
[62]
oncologic outcomes between minimally invasive and open RAMPS procedures, although some did note
that significantly fewer lymph nodes were harvested in minimally invasive approaches [63-66] . When
comparing laparoscopic RAMPS to laparoscopic DP using the traditional left-to-right approach, a recent
2022 study from Niu et al. showed laparoscopic RAMPS obtained more lymph nodes and trended towards
improved overall survival, although this did not achieve statistical significance .
[67]

Ongoing trials on minimally invasive distal pancreatectomy
The DP, minimally invasive or open, for malignancy (DIPLOMA) trial is the first randomized controlled
trial comparing minimally invasive (laparoscopic and robot-assisted) and open DP in patients exclusively