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Shannon et al. Mini-invasive Surg 2023;7:32 https://dx.doi.org/10.20517/2574-1225.2023.83 Page 3 of 15

In the subsequent decades, techniques aimed at improving the original PD technique; however, the
mortality rate for open PD was approximately 20%, with a perioperative morbidity rate between 40%-60% in
the 1970s [12,13] . Perhaps the next most important discovery in pancreatic surgery was the improvement in
outcomes by high-volume surgeons at high-volume centers. When performed in high-volume pancreatic
centers, mortality rates following pancreatectomy decreased to less than 5% [14,15] . The benefits of performing
pancreatectomy at high-volume centers include standardized evidence-based work-up, operative
techniques, and post-operative management resulting in shorter operative times, decreased blood loss, and a
subsequent improvement in outcomes [16,17] .

Introduction of minimally invasive pancreatic surgery
As the techniques and perioperative management for patients undergoing pancreatectomy were refined,
they were exclusively performed through a traditional open approach. For patients undergoing other
abdominal and thoracic procedures, minimally invasive surgery was shown to decrease hospital length of
[18]
stay (LOS) and surgical site infections and improve pain control .
[19]
The first laparoscopic PD was performed in 1994 for chronic pancreatitis by Drs. Gagner and Pomp .
However, given the lengthy complex operation of a pancreatectomy, the potential for increased cost, and
the worry of inferior oncologic outcomes, adoption of minimally invasive techniques initially remained low
for patients undergoing pancreatectomy. Additionally, the limited instrument range of motion, poor
ergonomics, and steep learning curve to perform three high-risk anastomoses also caused slow adoption of
[19]
laparoscopy for PD . Conversely, laparoscopic DP was first performed in the early 1990s and was adopted
far more readily as it does not require major reconstruction .
[20]
The advent of the da Vinci robotic surgical platform in the late 1990s was critical to the increased adoption
of minimally invasive techniques for pancreatic surgery. Robotic surgery more closely mimics open surgery
and provides the benefits of improved three-dimensional surgical field visualization, tremor reduction, and
additional instrument degrees of freedom . Indeed, the 3D vision during robotic PD has shown
[21]
improvement in performance and reduced anastomosis construction time . The first case of robotic DP
[22]
was described in 2003 by Melvin et al. for a patient with a symptomatic pancreatic cyst, while Giulianotti
et al. described the first experiences with robotic PD in the early 2000s [23,24] . While numerous retrospective
studies have demonstrated equivalent morbidity and mortality between minimally invasive and open
pancreatectomy, there are limited prospective data comparing these techniques [25-27] . The remainder of this
review will focus on analyzing the recent literature comparing minimally invasive vs. open pancreatic
surgery.

Recent trials on minimally invasive distal pancreatectomy
Completed trials
With the surge in minimally invasive surgical techniques, minimally invasive DP has been thoroughly
studied over the past decade. The seminal trial was the LEOPARD trial, which was a multicenter patient-
blinded randomized controlled trial conducted in the Netherlands between 2015 and 2017. Patients with
left-sided pancreatic tumors confined to the pancreas without vascular involvement were randomized to
either a minimally invasive (laparoscopic and robot-assisted) (n = 51) or open DP (n = 57). The primary
outcome was time to functional recovery, defined as independent mobility, pain control with oral
medication, and taking 50% of required caloric intake without intravenous fluids. The investigators found
that a minimally invasive approach had a significantly shorter time to functional recovery (4 days vs. 6
days, respectively, P < 0.001), lower operative blood loss (P < 0.001), and decreased delayed gastric emptying
grade B/C (P = 0.04) compared to an open approach. However, operative time was significantly longer for
minimally invasive PD. There was no significant difference seen in Clavien-Dindo grade III or higher