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Page 10 of 15 Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55

[108]
between the two depends on the preference of the surgeon and his familiarity with the technique .

Pancreaticoduodenectomy
Pancreaticoduodenectomy is still performed in the majority of centers with an open approach due to its
technical difficulty and the complex reconstructive phase. Available data on safety and feasibility of MIPD
are conflicting. Reports from low-volume centers showed an increased morbidity and mortality after
MIPD [119,120] , while experience in high-volume centers demonstrated a similar rate of mortality and
morbidity compared to OPD. Moreover, in high-volume centers, LPD showed a lower rate of DGE,
decreased blood loss, and a shorter hospital stay but a longer operative time [36,121,122] . Three randomized
clinical trials have been published with mixed results. Palanivelu et al. showed similar oncological and
[123]
perioperative outcomes in OPD and LPD. Conversely, the LEOPARD-2 trial was interrupted early because
of safety concerns due to a disproportionally high number of deaths in the LPD arm , while the
[124]
PADULAP trial reported a lower major complication rate and a shorter LOS and similar oncological
outcomes . No major differences in outcomes have been reported between LPD and RPD [126,127] . In view of
[125]
existing evidence, the Miami Guidelines concluded that insufficient data exist to recommend MIPD over
OPD. MIPD appears to be safe and feasible but only if performed by surgeons who have completed the
learning curve and if set in high-volume centers experienced in both pancreatic surgery and MIS.

HALS: DOES IT STILL HAVE A ROLE IN PANCREATIC SURGERY PRACTICE TODAY?
Analysis of trends in the use of MIS in pancreatic surgery showed how, with time, we had a steep increase of
MIDP, and the increase in number was paralleled by increasing complexity of procedures and a decrease in
conversion rate and operative time . Moreover, the proportion of procedures performed with hand
[42]
assistance decreased with time as surgeons became more skilled in MIS. It is worth noting that a recent
analysis showed that MIDP is only used in one third of eligible patients . Therefore, on the one hand,
[128]
HADP plays a very marginal role in high-volume centers, where surgeons have finished their learning
curve, while, on the other hand, there are still centers in the process of implementation of MIS where
HADP may play a fundamental role as a bridge to totally MIDP, easing the transition and shortening the
learning curve. Moreover, HADP, with its shorter operative time, may be preferred in patients with multiple
cardiological, pulmonary, and renal comorbidities who would not tolerate well the effects of prolonged
anesthesia and pneumoperitoneum . Furthermore, HADP may be used as an intermediary step in
[16]
conversion from MIDP to open in complex cases where manual assistance or tactile feedback is required or
in the case of intraoperative complications because it appears that converted hand-assisted cases have a
lower estimated blood loss and a shorter LOS than open [16,30] .

The role of MIS in PD is still not defined; MIPD can be performed in high-volume centers by experienced
surgeons with acceptable outcomes, but the results are difficult to be generalized. In the process of the
implementation of MIPD, LAPD may play a role as a bridge to totally laparoscopic PD allowing for a safer
transition [129,130] .

In conclusion, the choice of the right approach needs to be tailored to the patient with a focus on his or her
safety and to the surgeon keeping in mind his or her limits and expertise.

DECLARATIONS
Authors’ contribution
Conception, design, drafting and revision of the manuscript: Donisi G, Zerbi A