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Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55 Page 9 of 15

Figure 2. Trocars and mini-laparotomy placement in laparoscopic-assisted pancreaticoduodenectomy. The placement of trocars widely
changed among different reports. Proposed placement of trocars: (A) mini-laparotomy; and (B) ports for trocars placement.

MIDP for the treatment of pancreatic ductal adenocarcinoma, available data suggest the oncological
appropriateness of the procedure, but high-level evidence is still lacking. Oncological outcomes were
comparable in terms of resection margins, disease free survival, and overall survival, while the number of
harvested lymph nodes was found to be lower in one metanalysis and comparable in a second one [101,109,110] .
The DIPLOMA trial showed a higher R0 resection rate for MIDP, a less frequent Gerota’s fascia
[111]
resection, a lower number of harvested lymph nodes, and a comparable median survival. Randomized
clinical trials are ongoing, trying to give a definitive answer. Regarding the choice of the type of MIS
technique, several observational studies have been published comparing the robotic versus laparoscopic
approach. Theoretically, the robotic platform should provide advantages in terms of improved dexterity and
vision, allowing for completion of more complex procedures, but whether this translates into better
[112]
outcomes and cost-effectiveness in clinical practice is still controversial . Reported outcomes in the
literature are heterogenous: recent metanalyses showed a higher rate of splenic vessel preservation and a
lower conversion rate, but higher cost in Robotic DP compared to LDP [113,114] . Another metanalysis reported
a shorter LOS and an increase of spleen preservation rate at the expense of increased cost . Oncological
[115]
and postoperative outcomes, such as POPF rate and overall morbidity, were comparable. Other studies
showed no major differences in perioperative outcomes [116-118] . Therefore, the Miami Guidelines conclude
that both laparoscopic and robotic DP are considered valuable and equivalent options, and the choice