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Page 2 of 15 Shannon et al. Mini-invasive Surg 2023;7:32 https://dx.doi.org/10.20517/2574-1225.2023.83

INTRODUCTION
The pancreas is a retroperitoneal organ responsible for both endocrine and exocrine functions in the body.
Given its retroperitoneal location, surgery on the pancreas can be challenging as it is surrounded by many
critical structures, such as the portal vein, superior mesenteric artery and vein, and duodenum, among
others. Pancreatic adenocarcinoma (PDAC) is the most common indication for surgical resection of the
pancreas and other malignancies such as ampullary, neuroendocrine, bile duct, and duodenal tumors. In
[1-4]
addition, pancreatectomy may be indicated for benign etiologies, such as cysts, trauma, and pancreatitis .
Unfortunately, among cancer patients, only 15%-20% of them are potentially resectable at initial
presentation .
[5]
Surgical resection of the pancreas, however, carries a high risk of perioperative morbidity and mortality. The
post-operative potential sequelae of pancreatectomy, such as post-operative pancreatic fistula and delayed
gastric emptying, among others, potentially impact both short- and long-term quality of life. While
significant advances in surgical techniques and perioperative care have reduced mortality to less than 2% at
experienced centers, morbidity after pancreatectomy remains high .
[6]

Operative techniques for pancreatectomy vary based on the location of the pathology. Lesions in the body
or tail of the pancreas are amenable to distal pancreatectomy (DP), whereas lesions in the head and uncinate
process often require pancreaticoduodenectomy (PD). Both procedures are complex and traditionally have
been performed in an open fashion. In recent decades, however, the utilization of minimally invasive
pancreatectomy has increased due to its reported benefits over an open approach, including reduced pain,
decreased incidence of wound infection, and faster recovery. Herein, we present a narrative review of level 1
prospective randomized trials in the field of minimally invasive pancreas surgery compared to traditional
open approaches. The aim of this review is to discuss the history and evolution of minimally invasive
pancreas surgery and compare its safety and efficacy to open pancreatic surgery.

METHODS
We performed a comprehensive search strategy in the MEDLINE database for studies published between
January 2018 through February 2023. The following keywords and Medical Subject Headings were included
in our search: “pancreas”, “minimally invasive surgery”, AND “robotic surgery”. Records were excluded
during screening if not written in English. Reports were not retrieved if the full text was not available. Three
hundred thirty-four reports were assessed for eligibility and were excluded if they were meta-analyses
(n = 15), reviews other than systematic (n = 87), or non-Level 1 data (n = 207). A total of 25 reports were
included. Of these, five were clinical trials. All identified publications were reviewed for inclusion by two
reviewers (AS and NMB), and inconsistencies were addressed by discussion and consensus among the
reviewers.

History of techniques for open pancreatic surgery
The first radical resection of the duodenum and head of the pancreas was performed in a staged fashion by
Drs. Whipple, Parson, and Mullins in 1934 for a patient with ampullary cancer. Unfortunately, the patient
expired soon after the procedure due to anastomotic breakdown . Six years later, Dr. Whipple completed
[7,8]
the first one-stage PD for a patient with gastric cancer metastatic to the head of the pancreas . In the
[9]
interim, the first successful PD for PDAC was performed in 1937 by Alexander Brunschig . The pylorus-
[10]
preserving technique for PD was introduced in 1944, although it truly gained prominence in 1978 after
Traverso and Longmire proposed that sparing the pylorus would reduce the incidence of postgastrectomy
syndrome and marginal ulceration .
[11]