The era of minimally invasive pancreatic surgery: is the robot ready to replace laparoscopy for extended left pancreatectomy?

Minimally invasive distal pancreatectomy was first introduced in 1994 by Cuschieri, who reported the first laparoscopic distal pancreatectomy (1). The first robotic pancreas surgery (RPS), specifically robotic pancreaticoduodenectomy (RPD), was performed and reported by Giulianotti et al. in 2003 (2). RPS has seen a marked increase in adoption, and data from the United States showed that the use of RPD and robotic left pancreatectomy (RLP) increased from 1.1% to 7.5% and 2.2% to 19.4%, respectively, from 2010 to 2019 (3,4). Nevertheless, the recently published Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS) in 2023 only provided weak recommendations for the use of RPS over laparoscopy for malignant pancreatic diseases (5,6). However, only about 15% of patients with pancreatic cancer have localised disease amenable to resection at the time of presentation. Improvements in surgical techniques have allowed for the safe conduct of more radical pancreas resection procedures, such as extended or multivisceral resections, to improve curative R0 resection rates (7). The International Study Group for Pancreatic Surgery (ISGPS) defined extended resections as resection of any adjacent organs, and/or vascular structures (such as portal vein or superior mesenteric artery) (8). While the LEOPARD randomized controlled trial (RCT) showed reduced time to functional recovery for minimally invasive left pancreatectomy (MILP) compared with the open approach (9), there are currently no reported RCTs directly comparing extended robot-assisted left pancreatectomy (e-RLP) with extended laparoscopic left pancreatectomy (e-LLP).

Existing evidence remains limited to retrospective studies from single or limited institutions; therefore, high-quality, multicenter observational studies are essential to provide insight on the benefits of e-RLP. The recently published propensity score matched (PSM) multicenter study by Bruna et al. represents an important contribution to the evolving evidence base (10). The inclusion of 72 centers across 19 countries, coupled with prespecified propensity score matching and multiple sensitivity analyses, provides a pragmatic and real-world assessment of contemporary practice. This editorial aims to address several key aspects within the field of RPS (summarised in Figure 1): (I) the potential advantages of e-RLP over e-LLP; (II) current evidence comparing clinical outcomes between e-RLP and e-LLP; (III) recent technological advancements in robotic systems and how they may improve outcomes; (IV) the learning curve (LC) associated with MILP; and (V) patients’ receptivity towards robotic surgery (RS).

Figure 1 Diagram summarising the potential advantages and associated disadvantages with robotic surgery.

Commonly cited advantages of RS include its ergonomic benefits, such as enhanced instrument dexterity with 360° wrist articulation, reduced surgeon fatigue, superior three-dimensional (3D) visualisation, filtration of hand tremors, and autonomous control of the surgical camera. A recent survey conducted by Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on surgeons’ perspectives showed that surgeons felt that RS had better access to difficult areas and was more precise compared to laparoscopic surgery (LS) (11). This added level of precision and 360° wrist articulation in RS has been shown to outperform LS with better surgical scores and shorter operative times for biotissue pancreatic and biliary anastomoses compared to both 3D and two-dimensional (2D) laparoscopy (12). In the context of pancreatic surgery, this will be of greatest benefit for pancreaticoduodenectomy, where there is a need for three anastomoses. However, despite this, the study by Bruna et al. did not demonstrate significant improvement in post-operative outcomes after e-RLP compared to e-LLP, such as major morbidity (23.5% vs. 26.5%, P=0.599), but instead, had longer operative time (median 277 vs. 228 min, P<0.001) (10). In fact, one may reason that despite clear indicators of selection bias (before PSM), which were in favor of the robotic group, morbidity was not lower; a significantly higher proportion of patients in the e-RLP cohort had distally located (tail) tumors compared with the laparoscopic cohort (69.4% vs. 50.0%, P=0.001). Resection of pancreatic body tumours is more technically challenging in view of their proximity to the major vascular structures [i.e., portal vein, superior mesenteric vein (SMV) and superior mesenteric artery (SMA)], increased difficulty with obtaining clear margins, and the need for extended lymphadenectomy with dissection of lymph nodes along SMA and the hepatoduodenal ligament. The e-RLP cohort also had more small-bowel resections compared to e-LLP (26.3% vs. 9.2%, P<0.001). These resections, while technically classified as multivisceral, do not carry the same complexity as conventional multivisceral procedures involving the stomach, colon, or adrenal gland. Hence, the purportedly more complex robotic cohort in fact comprised technically easier distal cases with lower-impact multivisceral resections, introducing an intrinsic bias that potentially inflated the perceived equivalence of outcomes between e-RLP and e-LLP.

As discussed above, it remains uncertain whether the perceived advantages of e-RLP translate into superior clinical outcomes. To date, there are no RCTs that have directly compared RLP with LLP. Current literature is limited to retrospective observational studies, which are inherently susceptible to selection bias. In the study by Bruna et al. (10), a higher proportion of patients who underwent e-RLP had vascular involvement on pre-operative imaging (30.3% vs. 16.3%, P<0.001) compared to e-LLP, indicating more advanced tumour and greater surgical complexity. However, less than half of patients in each group had a diagnosis of pancreatic ductal adenocarcinoma (PDAC) and further one-fifth of those had T1 disease. Though superficially it appears that the e-RLP group had higher vascular invasion, the distal nature of the tumour and low rates of PDAC suggest that the e-RLP group was not as technically challenging as reported. Based on the overall cohort data (prior to PSM), it is reasonable to conclude that despite selection bias being in favour of the e-RLP group, clinical outcomes of e-RLP were not superior to e-LLP. PSM is therefore essential, and we applaud the authors for employing PSM to improve covariate balance. After PSM, the incidence of major morbidity (23.5% vs. 26.5%, P=0.599) and clinically significant post-operative pancreatic fistula of grade B or C (incidence 19.7% vs. 26.5%, P=0.215) remained similar between the two groups. One possible explanation for the lack of statistical significance may be inadequate sample size, since sample size calculation was not performed. Given that no a-priori power calculation was reported, the study may be underpowered to detect clinically significant differences. Nevertheless, given the lack of studies available, based on current evidence, e-RLP is non-inferior compared with e-LLP. The value of robotic assistance in this study may lie in the controlled execution of complex resections rather than demonstrable superior short-term outcomes over laparoscopy. Further research with larger cohorts and inclusion of additional clinical endpoints such as oncological outcomes, including lymph node yield, overall survival, and disease-free survival, is warranted.

Key disadvantages of RPS include the absence of tactile feedback, higher cost (there may also be limited subsidies/insurance coverage), and concerns regarding environmental sustainability (use of single-use disposable instruments, increased energy consumption and higher carbon footprint) (13). One of the most commonly used robotic systems—the da Vinci^TM surgical system^© (Intuitive Surgical, Inc., California, United States)—was first introduced in 1999. Since then, new generations of robotic systems have been introduced, including the da Vinci S, Si, Xi (fourth generation) and the newly launched da Vinci 5 (DV5) platforms. The DV5 system offers haptic feedback, more precise instrument articulation and upgraded imaging capabilities. The addition of haptic feedback has been shown to reduce tissue trauma; however, its influence on clinical outcomes has not yet been demonstrated by Chang et al. (14). A longer operative time was also observed with e-RLP compared with e-LLP in the study by Bruna et al. (10), and this difference remained significant even after PSM for extent of the resection and vascular involvement. Longer operative time was traditionally attributed to the additional time required for the setup and docking of the robotic system. However, such delays are expected to decrease with growing experience and the introduction of newer platforms such as the da Vinci^TM Xi system, which offers more efficient and streamlined docking processes. To add on, cost disparities between laparoscopic and robotic surgeries have widened over the past decade (15). Hence, careful justification is necessary before offering RS as a “standard practice” to patients.

Another limitation of minimally invasive surgery lies in the necessity to surpass the LC before attaining technical proficiency and fully realising its advantages. A systematic review by Chan et al. reported that at least 26 cases and 21 cases are required to overcome the LC for LLP and RLP, respectively (16). Notably, most existing studies that compare RPS with LPS, including that by Bruna et al., are not based on single-surgeon outcomes and often do not account for the operating surgeons’ experience levels. The outcomes reported by Bruna et al. also did not stratify outcomes based on surgeon experience, which may influence operative time and post-operative complications. While it is assumed that all performing surgeons have a professional level of surgical expertise, in the context of RPS—a rapidly developing field—not all surgeons may be well-versed with RS.

Lastly, patients may have reservations or misconceptions about RS. A local survey conducted in a specialist outpatient surgical clinic in Singapore showed that only a minority of surveyed participants (n=159, 33.7%) preferred the use of RS (17); however, of those participants, preference for the use of RS was independently associated with the perception that RS yielded better results (odds ratio 1.61, 95% confidence interval: 1.06–2.45). Surgeons should provide patients with comprehensive counseling regarding the potential benefits, existing evidence, and limitations of RS. A key drawback lies in the substantially higher costs incurred and their associated carbon footprints compared with LS. These, compounded with the absence of demonstrated superiority in postoperative outcomes, make the case for public policy and generalised adoption weak. Moreover, in cases requiring conversion to open surgery, the patient must still bear the expenses associated with the use of disposable instruments and the robotic system.

In summary, despite the postulated ergonomic advantages and higher incidence of pancreatic tail tumours in those who underwent e-RLP, post-operative outcomes are similar to e-LLP. These findings suggest that e-RLP should not be viewed as a default alternative to laparoscopy, but rather as a selectively deployed tool within high-volume centers and appropriately governed programs. Until prospective or cost-effectiveness data emerge, adoption should remain conditional in anatomically complex cases managed by surgeons who have surpassed the LC.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-1-992/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-1-992/coif). The authors have no conflicts of interest to declare.

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