Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis

Abstract

Background

Robotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent.

Method

A systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model.

Result

This review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates.

Conclusion

RPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.

Introduction

Over the last decade, robotic surgery has emerged as a potential valid alternative to conventional laparoscopic surgery. Advantages of current robotic surgical platforms include 3D visualisation of the surgical field and improved instrument dexterity which may facilitate complex dissection and surgical reconstructions. In addition the use of an ergonomic surgical console may reduce surgeon fatigue for long and complex procedures which is one of the reasons why the laparoscopic approach remains unpopular [1]. RPD may also encourage more surgeons to take up complex minimally invasive techniques which they previously would not have considered doing. Robotic surgery has been shown to be superior to conventional laparoscopic surgery in a variety of different complex surgical procedures. For example, in radical prostatectomy the robotic approach has been associated with an earlier return of sexual function when compared to conventional laparoscopic surgery, which is attributed to an increased ability to preserve the cavernous nerve [2,3]. A similar reduction in impotency rates have been reported in robotic rectal surgery, presumably for similar reasons [4].

Minimally invasive PD (MIPD) has been gaining popularity in recent years, with systematic reviews suggesting MIPD (both laparoscopic and robotic) were associated with significantly less blood loss and lower rates of margin-positive resections compared to conventional (open) PD [[5], [6], [7]]. A recent meta-analysis comparing LPD and open PD for the management of periampullary malignancies have concluded that the use of the laparoscopic approach did not impact on short-term survival or the incidence of pancreatic fistula. The laparoscopic approach was however associated with a shorter duration of hospital stay and lower overall complications [8]. Whether the use of a robotic approach may prove to be superior to both the conventional laparoscopic and open techniques for complex pancreatic resections although this still remains to be determined [9].

To date, evidence comparing the benefits of robotic PD (RPD) and LPD is limited [10], and more data is still needed to offer clearer guidance on the future development of minimally invasive pancreatic surgery. The aim of this systematic review was to summarise current evidence for laparoscopic of robotic PD and perform meta-analysis to evaluate the current evidence regarding RPD and to compare its advantages with the conventional laparoscopic approaches.