# Perioperative Outcomes in Robotic, Laparoscopic, and Open Distal Pancreatectomy: A Network Meta-Analysis and Meta-Regression

## TL;DR

This study compares robotic, laparoscopic, and open distal pancreatectomy techniques and finds robotic surgery offers better short-term outcomes, though results may depend on the hospital's expertise.

## Contribution

A network meta-analysis and meta-regression comparing perioperative outcomes of three distal pancreatectomy techniques using data from 67 studies and 18,113 patients.

## Key findings

- Robotic and laparoscopic surgeries reduced blood loss, transfusion rates, and hospital stays compared to open surgery.
- Robotic surgery had the lowest conversion rate and significantly reduced 30-day mortality.
- Readmission and 90-day complication rates were similar across all approaches, suggesting disease factors may play a larger role.

## Abstract

Minimally invasive techniques are increasingly used for distal pancreatectomy, yet uncertainty remains regarding the relative benefits of robotic, laparoscopic, and open approaches. Using a network meta-analysis of 67 studies and over 18,000 patients, we compared short-term perioperative outcomes across the three techniques. We found that both robotic and laparoscopic procedures reduced blood loss, transfusion rates, and hospital stay compared to open surgery. Notably, robotic surgery was associated with the lowest conversion rate and significantly reduced 30-day mortality, while laparoscopic outcomes were generally intermediate. However, readmission and 90-day major complication rates did not differ significantly, suggesting that these outcomes may be influenced more by disease-specific factors than by surgical approach. Importantly, most robotic data originated from high-volume expert centers, limiting generalizability, and long-term oncologic outcomes were not available. Overall, our findings support the perioperative safety and efficacy of minimally invasive distal pancreatectomy, while emphasizing the need for cautious interpretation of robotic advantages beyond high-volume practice.

Background: Distal pancreatectomy (DP) is a potentially curative procedure for tumors of the pancreatic body and tail. Minimally invasive DP (MIDP), including laparoscopic and robotic techniques, is increasingly being adopted. This study aimed to evaluate the perioperative outcomes of robotic DP (RDP) in comparison with laparoscopic and open approaches using a network meta-analysis and meta-regression. Methods: We systematically searched MEDLINE, EMBASE, Web of Science, and Scopus for studies comparing at least two surgical approaches. Both Bayesian and frequentist network meta-analyses were performed. Results: Sixty-seven studies involving 18,113 patients met the inclusion criteria. Surface under the cumulative ranking (SUCRA) analysis showed that RDP ranked first in 84.6% of measured parameters. Laparoscopic DP (LDP) demonstrated intermediate performance, whereas open DP (ODP) consistently ranked lowest. Operative time was significantly longer for RDP compared with ODP (MD = +25.93 min, 95% CI 7.68–44.18), while LDP and ODP were comparable. RDP significantly reduced 30-day mortality (OR = 0.37, 95% CI 0.16–0.84) and conversion rates compared with LDP (OR = 0.30, 95% CrI 0.22–0.40). Both minimally invasive approaches (RDP and LDP), compared with open surgery, were associated with reduced blood loss (−304 mL and −273 mL), fewer transfusions (OR 0.25 and 0.30), smaller transfused volumes (−1.98 and −1.86 units), shorter ICU stays (−4.0 and −2.3 days), fewer reinterventions (OR 0.45 and 0.56), and shorter hospital stays (−8.8 and −6.9 days), respectively. Conclusions: Although associated with longer operative time, RDP appears safe and may confer significant advantages over both laparoscopic and open surgery, including reduced 30-day mortality, lower conversion rates, and improved perioperative outcomes, particularly when performed in high-volume, well-equipped centers.