Devil’s advocate: is there any real advantage of mini-invasive pancreaticoduodenectomy versus open pancreaticoduodenectomy?

Abstract

: The development of minimally invasive surgery (MIS) using laparoscopy and robotics has revolutionized the postoperative course of digestive surgery. By decreasing surgical trauma, the minimally invasive approach minimizes postoperative pain, enhances postoperative recovery, and reduces length of stay and hospital costs. This “surgical revolution”, which has spanned over the last thirty years, has not fully advanced the field of pancreatic surgery. Pancreaticoduodenectomy (PD), which is usually performed by an open approach, still represents a technically demanding operation with a steep learning curve and high postoperative morbidity and consequent mortality. The postoperative complications of PDs require treatment from multidisciplinary healthcare management teams in highly experienced institutions, so PDs should be restricted to high volume centres. In this article, we have reviewed the reasons for the reluctance of pancreatic surgeons to perform PDs by MIS, the clinical outcomes from minimally invasive PDs, and the expectations of pancreatic surgeons of MIS. After reviewing the literature, morbidity and mortality of MIS PD seems to be comparable to open surgery, but a recent randomized trial was prematurely interrupted due to higher mortality in the laparoscopic arm. Long-term survival of patients with pancreatic adenocarcinoma seems to be comparable between MIS PD and open surgery. MIS PD achieves statistically significantly decreased blood loss at the expense of increased operative time compared with open PD. Quality metrics and new scores should be developed in order to further evaluate and compare the outcomes from open and/or MIS pancreatic resection.