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Page 2 of 15 Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55

operative field visualization with 3D imaging. Nonetheless these advantages have to be balanced with
drawbacks such as lack of haptics and high cost in terms of both initial investment in purchasing the robotic
platform and single operation cost.

MIS IN THE PANCREATIC SURGERY FIELD: A STEEP PATH
Despite all the hype around these new technologies, the implementation and diffusion of MIS have been
hampered by the large amount of time and dedication necessary to master the techniques to have results
comparable to the open approach. The concept of learning curve became particularly popular with the
advent of minimally invasive surgery, when surgeons needed to completely rethink their abilities and adapt
them to new techniques and technologies. It has also been postulated that the learning curve appears to be
longer in MIS relative to open surgery, and that the curve becomes steeper and steeper with the increasing
complexity of surgical procedures . For complex major abdominal surgeries, a great number of procedures
[5]
is required to master the technique, and there may be dangerously high morbidity and mortality rates at the
beginning of the learning curve. This has been particularly the case of pancreatic surgery.

Despite the appeal of MIS and its widespread adoption in several fields of surgery, the attitude of pancreatic
surgeons has been initially tepid. On the one hand, there was the conceptual problem of whether in complex
and demanding surgical operations such as pancreatic resections the size of the incision can truly be
considered the main contributor to surgical trauma. On the other hand, some peculiar aspects of pancreatic
surgery have initially hampered the widespread diffusion of the minimally invasive approach in this field:
the peculiar retroperitoneal location of the pancreas, its delicate texture and proximity to major vessels, the
complexity of the dissection, the concerns regarding oncological safety in the case of malignancy, the
difficulty of the anastomotic components, and the still relatively high morbidity and mortality that
characterize pancreatic resections [6-10] . Another more practical matter is the relative rarity of pancreatic
diseases and the complexity of most cases, which make them not suitable to be approached minimally
invasively by surgeons at the beginning of their learning curve; the result is an even longer time to reach
proficiency and an acceptable morbidity and mortality rate .
[11]

Reports of the initial experience with totally laparoscopic pancreatic surgery showed no apparent advantage
for pancreaticoduodenectomy, with no improvement in postoperative outcomes and increased morbidity.
Conversely, the results are promising for distal pancreatectomy, since it was associated with acceptable
operative time and reduced morbidity and length of stay (LOS) .
[12]

HAND-ASSISTED LAPAROSCOPIC SURGERY
Rationale and limitations
To overcome the difficulties in adaptation of complex procedures from an open approach, some hybrid
techniques have been developed for laparoscopy.

One of the proposed approaches is hand-assisted laparoscopic surgery (HALS): a mini-laparotomy is
planned through which the surgeon can insert his or her hand covered by a glove or a hand port that
prevents the loss of the pneumoperitoneum. This allows for the surgical operation to be performed via
laparoscopy but with the help of an intra-abdominal hand. At the beginning, this technique was greeted
with skepticism because of the need to perform a laparotomic incision, which is in direct contrast with the
principle of minimal invasivity and because of the lack of adequate instruments able to maintain the
pneumoperitoneum with an intra-abdominally inserted hand . However, with the development of
[13]
appropriate instruments, HALS found its niche in enabling the surgeon to start approaching major
abdominal operations in laparoscopy, with as safety net the familiarity and the expertise of having a hand