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Tschuor et al. Mini-invasive Surg 2020;4:72 I http://dx.doi.org/10.20517/2574-1225.2020.39 Page 9 of 12

Figure 8. Hepaticojejunostomy

DISCUSSION
Robotic pancreatic surgery provides several advantages and enables the surgeon to perform complex
[12]
resections and reconstructions by facilitating supraphysiological movements with the robotic instruments .
Since the first report of a robotic-assisted distal pancreatectomy in 2001, total pancreatectomies,
pancreatic tumor enucleations, pancreaticoduodenectomy, central pancreatectomy and Appleby procedures
have been performed, indicating a promising future. Results of randomized control trials comparing robot-
assisted PD with the laparoscopic or open approach are lacking. Patient recruitment for one randomized
control trials in China and one in the USA started in 2020, and results are expected for 2024. The
international consensus statement on robotic pancreatic surgery published last year reveals that the level of
[13]
evidence still remains moderate to low for the robotic platform .
A review of our own experience revealed longer operative times of approximately 136 min when compared
[14]
with our open PD cohort . However, robotic PD resulted in less blood loss (200 mL lower), a shorter
intensive care unit stay, a lower 30-day complication rate, and no difference in total costs compared with
open PD [15,16] .

Perhaps more importantly, we found that with increasing experience, the pancreatic fistula rate could
be reduced to below that of most open as well as laparoscopic series (7.4% vs. 12%) and that the robotic
approach may offer improved oncologic outcomes.

The significantly higher lymph node yield and decreased inflammatory response demonstrated in robotic
surgery may improve overall survival [4,17] .

Multiple single or multi-institutional retrospective studies to compare specific outcomes between robotic,
laparoscopic and open approaches are reported [6,14-16,18-24] . A large systematic review examined data from
13 retrospective series . It compared the outcomes of 738 patients who underwent robotic and open PDs
[25]
between 2000 and 2016. The data showed that the robotic approach was associated with longer operative