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improved outcomes after 10 LPD cases; however, outcomes may not plateau until 50 cases [22,23] . In 2010, of
[24]
the institutions with surgeons that actively performed LPD, only 8% performed at least 10 LPDs per year .
Therefore, even when a surgeon achieves proficiency with LPD, there may not be a sufficient case volume to
maintain said proficiency. Second, the outcomes data are equivocal regarding the superiority of LPD
compared to open PD. Early retrospective studies demonstrated shorter lengths of stay, decreased rates of
complications, and oncologically safe outcomes [25,26] . Conversely, other studies suggested increased
morbidity and mortality after LPD [24,27] . Recently, three randomized controlled trials published data
comparing perioperative outcomes between open PD and LPD [28-30] . The first two published trials (PLOT
and PADULAP) were single-institution studies, each involving two surgeons, that randomized 64 patients
(32 LPD and 32 open PD) and 66 patients (34 LPD and 32 open PD), respectively [28,29] . Both studies
demonstrated shorter lengths of hospital stay and longer operating times with LPD. While both studies
showed equivalent oncologic outcomes between the two approaches, the PADULAP trial also showed better
post-operative morbidity outcomes with LPD. Of note, only one patient required conversion to open in the
PLOT trial, whereas eight patients (23.5%) were converted to an open approach in the PADULAP trial. The
LEOPARD-2 trial was a multicenter, patient-blinded, randomized phase 2/3 trial involving four high-
volume centers in the Netherlands . After 99 patients underwent surgery, the study was terminated early
[30]
due to higher 90-day complication-related mortality in the LPD group (five [10%] vs. 1 [2%]; P = 0.20), and
no clear demonstrated advantage. There were no significant differences in time to functional recovery,
Clavien-Dindo grade III or higher complications, or grade B/C POPF between the two approaches. Lower
annual volume of LPDs at participating institutions during LEOPARD-2 (median 11) may partially explain
the conflicting results compared to PLOT and PADULAP trials. While these studies provided prospective
data, the generalizability of the results is limited by low enrollment, varying experience, or high approach
conversion rates. A 2020 systematic review and meta-analysis of these randomized controlled trials revealed
no statistically significant differences between either PD approach regarding the length of stay, post-
operative complications, and mortality . As it stands, LPD remains the dominant minimally invasive
[31]
approach in areas where cost and availability limit alternative minimally invasive approaches.

ROBOTIC SURGERY
Dr. Kwoh performed the first robotic/computer-assisted surgery, a brain biopsy, with the PUMA 560 in
1985 . Private and government collaborations over the next decade led to many advances in robotic
[32]
technology, culminating in Mona (Intuitive®), the first robotic surgical system to move to human trials. In
1997, Dr. Himpens, with Dr. Cardiere at the bedside operating the endoscopic camera, performed a
cholecystectomy using the Mona robotic surgical system . Despite the early success of the Mona system,
[33]
certain limitations prohibited further implementation, which then informed the development of the da
Vinci robotic system. Since receiving FDA approval for abdominal surgeries in July 2000, da Vinci iterations
have expanded across the globe . Their global reach even includes real-time tele-surgery, as was
[34]
demonstrated in 2001 when a New York-based surgeon performed a tele-robotic cholecystectomy on a
[35]
patient in Strasbourg, France .
Robotic surgery has multiple advantages compared to laparoscopic surgery. First, the instruments move in
the same direction as the surgeon’s hand, providing strong hand-eye coordination. As a result, the
instruments more accurately function as an extension of the surgeon’s hands rather than a device needing
counterintuitive movements to get the desired effect. Second, the robotic platform eliminates physiologic
tremors, both for the instruments and the camera, and provides greater degrees of freedom than the human
hand. This allows for fine, precise movements performed with a greater range of motion. Third, the surgeon
can have immediate control of up to three instruments. The surgeon also maintains control of the camera
throughout the operation. Furthermore, the robotic camera uses a 3D high-definition camera with superior