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[36]
spatial awareness and visualization compared to laparoscopic cameras . Fourth, dual console robotic
platforms offer educational training advantages over other forms of MIS, such as expeditious instrument
exchange between the primary surgeon and assistant, as well as an interactive screen to guide tissue plane
and target identification. Finally, operating on the robotic console provides an ergonomically superior
experience to both open and laparoscopic surgery for the surgeon .
[37]
However, robotic surgery has some notable hurdles to broader adoption. Significant upfront costs and
maintenance fees are prohibitive for many institutions. Moving forward, device competition may drive
down costs over the next decade as multiple robotic platforms enter the market . Second, the absence of
[38]
tactile sensation can lead to unintended instrument action and accidental patient injury, especially when the
[39]
instrument is not within view . Furthermore, despite technological advancements in the field, the
sterilization of robotic tools with sodium hydroxide or sodium hypochlorite poses a challenge in the
development of sensors able to withstand these corrosive chemicals . Soon, emerging haptic innovations
[40]
may provide solutions to resolve these force feedback issues . Finally, the need for an accompanying legal
[40]
framework for the robotic platform provides another logistical hurdle for any prospective institution
looking to incorporate robotic surgery .
[41]

Despite these challenges, robotic surgery offers a novel evolution in MIS, providing many mechanical
advantages over laparoscopic and even open surgery, expanding the indications for MIS, and improving
patient outcomes for a variety of conditions. In healthcare settings with sufficient expertise and resources,
robotic approaches have achieved broad adoption for many procedures in urology, colorectal surgery,
cardiothoracic surgery, otolaryngology, and gynecology. As such, robotic surgery utilization is growing,
while rates of laparoscopic procedures have stalled and, in some cases, decreased [42,43] .

ROBOTIC PANCREATICODUODENECTOMY
In 2010, Giulianotti et al. published an early multi-institutional study of RPDs showing R0 resection rates
[44]
and mortality rates comparable to open PD and LPD . Despite these promising results, the rate of POPF
was 31.3%, highlighting a clear area for improvement. Several other retrospective studies of RPD have been
published since, demonstrating acceptable rates of POPF while achieving an adequate lymphadenectomy
and acceptable mortality, morbidity, and margin-negative resection rates [Table 1] [45-54] . A study by Nguyen
et al. revealed that RPD was safe for patients with aberrant artery anatomy, such as a replaced or accessory
left hepatic, right hepatic, or common hepatic artery . Jin et al. reviewed PDs with venous resection and
[55]
reconstruction (VR) in a single high-volume institution and found that RPD-VR had lower lymph node
resections but no difference in 3-year survival rates, reconstructed venous patency, or post-operative
mortality when compared to open PD-VR .
[56]

In general, retrospective studies comparing RPD to open PD demonstrate shorter length of hospital stay,
less estimated blood loss, and longer mean operating times for RPD with comparable mortality, morbidity,
POPF, and margin-negative resection rates [54,57-60] . Multiple studies using propensity score matching confirm
these results for patients that underwent RPD [61-63] . Additional retrospective and non-randomized
prospective studies have demonstrated comparable and even favorable outcomes with RPD compared to
open PD [Table 2] [64-72] . A recent meta-analysis by Fu et al. evaluated 21 studies comparing RPD to open PD,
five of which contained patients with pancreatic cancer . Their analysis demonstrated significantly longer
[73]
operative times in RPD as well as less estimated blood loss, fewer overall complications, including POPF,
shorter length of hospital stay, and lower 90-day mortality. While subgroup analysis was not performed due
to the clumping of patients with multiple diseases in each study, the results suggest that RPD has a favorable
short-term outcome profile compared to open PD in appropriately selected patients. Another recent meta-