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Page 2 of 11 Riachi et al. Mini-invasive Surg 2023;7:14 https://dx.doi.org/10.20517/2574-1225.2022.120

INTRODUCTION
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies, with a 5-year
[1,2]
overall survival rate of 11% . By 2030, PDAC is expected to be the second leading cause of cancer-related
mortality in the United States . For patients with PDAC, complete surgical resection provides the only
[3]
opportunity for long-term survival. Pancreaticoduodenectomy (PD), commonly referred to as the Whipple
procedure, is the surgical procedure of choice for tumors in the head and/or uncinate process of the
pancreas . PD has undergone significant modification and refinement over the decades but remains a
[4]
technically demanding procedure associated with significant morbidity.

In 1898, the first documented PD was performed by Dr. Alessandro Codivilla in Italy, and a successful
resection of ampullary cancer was performed by his contemporary Dr. William Stewart Halsted in
Baltimore . The procedure was later modified by Dr. Walter Kausch to include en bloc resection of parts of
[5]
[6]
the pancreas and duodenum in 1912 . The procedure was further developed by its namesake, Dr. Alan
Oldfather Whipple, into a two-stage procedure in 1935 and finally into a one-stage procedure in 1940 .
[6]
For much of the 20 century, PD-associated mortality prohibited wider adoption due to mortality rates of
th
up to 25%. However, in the 1980s, advances in surgical technique and perioperative management led to a
dramatic decrease in perioperative mortality and improved outcomes . Today, patients treated at high-
[7]
volume centers by experienced surgeons can expect post-operative mortality rates of less than 5% . Despite
[8]
improvements in mortality, PD is associated with post-operative morbidity rates of 30%-60%.
Complications include delayed gastric emptying, pancreatic fistula (POPF), chyle leaks, anastomotic leaks,
hemorrhage, surgical site infections, and intra-abdominal abscesses [9,10] .

Minimally invasive techniques were first utilized in the approach to PD in 1994 when Ganger and Pomp
reported the first totally laparoscopic PD (LPD) . Less than a decade later, the first robotic PD (RPD) was
[11]
performed by Giulianotti in Italy . Today, due to the development and implementation of robotic training
[12]
curricula in residency and fellowship programs, the prevalence of RPDs has significantly increased. While
prospective randomized trials comparing the different approaches to PD are lacking, recent retrospective
studies demonstrate that RPD can be performed safely with comparable outcomes in appropriately selected
patients. In this article, we discuss the progression of minimally invasive PD, the available data on the
different approaches to PD, and, finally, active areas of innovation involving RPD.

LAPAROSCOPIC PANCREATICODUODENECTOMY
Compared to open surgery, minimally invasive surgery (MIS) results in less post-operative pain, shorter
length of stay, improved cosmetic results, and faster return to activities of daily life . However, to access
[13]
these benefits for patients, surgeons must develop entirely new skill sets to perfect laparoscopic techniques.
Challenges include optimizing a 2-dimensional screen in a 3-dimensional field, using visual cues to
[14]
overcome reduced tactile sensation, and suturing and dissecting with fewer degrees of freedom . However,
due to the integration of laparoscopic training curricula into residency and fellowship education, the
innovation of more efficacious MIS instruments, and the refinement of MIS technique, the laparoscopic
approach has become the standard of care for many surgical procedures including oncologic resections [15-19] .

Unlike laparoscopic distal pancreatectomy, the standard of care approach for distal pancreatectomy in most
patients, LPD has failed to gain similar traction among surgeons that perform PD aside from a few select
institutions [20,21] . Two potential reasons to explain the lack of broader adoption of LPD include the
challenging learning curve and unclear association with improved outcomes compared with open PD. First,
the reported threshold for proficiency in LPD varies between studies, with some reports suggesting