Minimally Invasive Surgical Approach Compared With Open Pancreaticoduodenectomy: A Systematic Review and Meta-analysis on the Feasibility and Safety

Background: Laparoscopic and robotic pancreaticoduodenectomy have started utilization tentatively; however, the clinical benefits are still controversial. This study aims to evaluate the safety and efficiency of minimally invasive pancreaticoduodenectomy. Methods: A systematic literature search was performed through PubMed, EMBASE, and Cochrane Library database without restriction to regions, publication types, or languages. Nine studies that compared laparoscopic/robotic with open pancreaticoduodenectomy were included. Fixed or random-effects models was used to measure the pooled estimates. Sensitivity and subgroup analysis were performed to evaluate the study quality. Results: Patients who underwent minimally invasive pancreaticoduodenectomy experienced longer operative time (P = 0.007), but the estimated blood loss (P = 0.007), length of stay, (P = 0.02), and wound infection (P = 0.04) decreased. Perioperative complications, such as pancreatic fistula, delayed gastric emptying, hemorrhage, bile leakage, reoperation, and mortality, were of no significant differences. Pathologically, lymph node number was similar (P = 0.11); meanwhile, margin R0 ratio was higher in minimally invasive approach group (P = 0.03). Subgroup analysis manifested robotic surgery spent comparable surgical time (P = 0.16) as laparotomy, with earlier discharge (P = 0.04). Conclusions: This meta-analysis indicates minimally invasive pancreaticoduodenectomy may be associated with shorter hospital stay, less estimated blood loss, and positive margin rate without compromising surgical safety as open surgery. Surgical duration of robotic method could even be equivalent as laparotomy. Minimally invasive approach can be a reasonable alternative to laparotomy pancreaticoduodenectomy with potential advantages. Nevertheless, future large-volume, well-designed RCTs with extensive follow-up are awaited to confirm and update the findings of this analysis.