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Summary: This literature review reflects the present evidence on minimally invasive pancreatic surgery, differentiating between distal pancreatic resection and pancreatoduodenectomy for pancreatic cancer. The review analyzed studies comparing minimally invasive and open pancreatic surgery in PubMed, the Cochrane Library, and the WHO Trial Register according to the following MeSH search strategy: MeSH items: pancreatic surgery, minimally invasive surgery, robotic surgery, laparoscopic surgery, pancreatoduodenectomy, and distal pancreatic resection. In systematic reviews and meta-analysis, minimally invasive distal pancreatectomy (MI-DP) has been shown to result in shorter hospital stays, less blood loss, and better quality of life than open distal resection (ODP) with similar morbidity and mortality. Meta-analyses have suggested similar oncological outcomes between the two approaches. Minimally invasive pancreatoduodenectomy (MI-PD) has been shown to offer advantages over open surgery, including shorter length of stay and less blood loss, by expert surgeons in several studies. However, these studies also reported longer operative times. As the procedure is technically demanding, only highly experienced pancreatic surgeons have performed MI-PD in most studies, so far limiting widespread recommendations. In addition, selection of cases for minimally invasive operations might currently influence the results. Registry studies from dedicated groups such as the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS) and randomized controlled trials currently recruiting (DIPLOMA‑1 and 2, DISPACT-2) will bring more reliable data in the coming years. In conclusion, both MI-DP and MI-PD have shown some advantages over open surgery in terms of shorter hospital stays and reduced blood loss, but their effectiveness in terms of oncological outcomes is uncertain due to limited evidence. The study highlights the need for further randomized controlled trials with larger sample sizes and registry studies to further evaluate the safety, efficacy, and oncological outcomes of minimally invasive pancreatic resections. [ABSTRACT FROM AUTHOR]

Objective: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE IIGRS tool for guideline quality assessment and external validation by a Validation Committee. Results: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. [ABSTRACT FROM AUTHOR]

Abstract Background The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. Methods The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital’s trauma center had been verified; and (4) the hospital’s surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. Results The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P

Background: The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. Methods: The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital's trauma center had been verified; and (4) the hospital's surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. Results: The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien–Dindo grades III–IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732). Conclusion: Despite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results. [ABSTRACT FROM AUTHOR]

Background: Although only a low percentage of abdominal surgical interventions are performed using a robotic platform, the total number has significantly increased in recent years and robotic surgery (RS) is no longer limited only to university hospitals. Despite the increasing popularity and many innovations in the field of robotic surgery with new devices, the data situation is confusing. Objective: This review deals with the current areas of application of robotic devices in abdominal surgery and whether there are any advantages compared to laparoscopic surgery (LS). Material and methods: The current international literature was evaluated and is critically discussed with a particular focus on clinical trials. Results: While the disadvantages include high costs and longer times of surgery, the advantages are a stable optical platform and the high mobility even in confined spaces; however, no high-quality, randomized controlled trial in abdominal surgery is currently available that could demonstrate an advantage of RS compared to LS. Conclusion: Although no clear advantages of RS for the patients could so far be demonstrated, it seems to be at least equivalent to LS. Undisputed is the level of comfort for the surgeon. Once the costs of RS can be reduced, LS will probably be replaced for most indications. [ABSTRACT FROM AUTHOR]

Background: Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. Methods: The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. Results: Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. Conclusions: The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.

Background: Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS. Methods: This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon. Results: The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto‐splenectomies (en bloc gastric resection) and 10 spleen‐saving‐RDP. Splenic preservation was successful in 10/11 attempted spleen‐saving‐RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port‐site hernia and no 30‐day/in‐hospital mortalities. The median post‐operative stay was 6.5 (range: 3–36) days and there were six (20%) 30‐day readmissions. Conclusion: Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery for pancreas has advanced at a steady pace in recent years. Although proximal pancreatic resection is still a formidable task, distal resection has become routine with a laparoscopic approach. The recent introduction of the Da Vinci Robotic Surgical System has helped to make this complex procedure much more feasible, efficient, and safe. In this paper, we describe our technique for robot-assisted distal pancreatectomy with splenic preservation, which can be broken down into five steps in a medial-to-lateral progression. Preservation of splenic vessels is routine, although in certain instances a Warshaw's technique is employed. The advantages of the robotic approach are described. [ABSTRACT FROM AUTHOR]

Background: Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. Methods: The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. Results: Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. Conclusions: The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula. [ABSTRACT FROM AUTHOR]

Compared with traditional surgery, minimally invasive surgery has the advantages of less complications and quick postoperative recovery. Therefore, modern surgery is developing towards the direction of minimally invasive. while minimally invasive pancreatic surgeries are rather challenging and develop slowly, due to the limits with different operation techniques, long operation time and different operation outcomes, which are only carried out in high-volume pancreatic surgery centers. This special coverage topic will elaborate our long-term experience and the key points to overcome the operational difficulties in laparoscopic and robotic pancreas surgery. In order to promote the development of minimally invasive pancreatic technology and benefit more patients (especially pancreatic cancer patients), some suggestions and prospects with the latest research results at home and abroad are put forward for the future development of this field., (Copyright© by Editorial Board of Journal of Sichuan University (Medical Science Edition).)

Background: Described for the first time in 2003, the robotic pancreatic surgery shows interesting results. The evaluation of post-operative outcomes is necessary once we describe an innovative surgical approach., Methods: We have performed a retrospective analysis of a prospectively maintained database on robotic pancreatic surgery including malignant and benign indications for surgery., Results: A total of 50 consecutive patients underwent robotic pancreatic surgery (26 pancreatico duodenectomy and 24 distal pancreatectomy) between January 2012 and July 2015 in a single centre. The overall operative time was 425 (390-620) min. In a subgroup of highly selected malignant tumours, we were able to achieve 88% of R0 resection with robotic approach. A number of lymphnodes rose significantly with growing experience (p = .025). The overall major complication rate (15%), as well as pancreatic fistula rate (16%) were acceptable. The two-year overall survival for the whole group was 65%., Conclusion: The robotic pancreatic surgery in a highly selected group of patients seems safe and feasible. The cost-effectiveness and long-term oncologic outcomes need further investigations.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation., (© 2018 Wiley Periodicals, Inc.)