# From Open to Robot-Assisted Pancreatoduodenectomy: What RCTs Really Show

## TL;DR

Minimally invasive pancreatoduodenectomy is safe and effective in high-volume centers but requires careful consideration of costs and surgeon experience.

## Contribution

Synthesizes RCT evidence to clarify the true benefits and limitations of minimally invasive pancreatoduodenectomy.

## Key findings

- Laparoscopic approaches reduce blood loss and recovery time but have longer operative times.
- Robotic surgery shows mixed results with higher costs and increased risks of certain complications.
- Both minimally invasive methods achieve oncological outcomes comparable to open surgery.

## Abstract

Introduction: Minimally invasive pancreatoduodenectomy (MIPD), including laparoscopic (LPD) and robotic approaches (RPD), has gained increasing attention as an alternative to open pancreatoduodenectomy (OPD). Despite rapid technological progress, concerns persist regarding safety, reproducibility, and oncological adequacy. The publication of randomized controlled trials (RCTs) provides essential high-level evidence to reassess the true benefits and limitations of MIPD. Methods: This narrative review synthesizes all available RCTs comparing LPD and RPD with OPD. Major domains evaluated include mortality, major morbidity, intraoperative parameters, postoperative recovery, oncological outcomes, conversion, costs, and the influence of surgeon experience and institutional volume. The objective is to contextualize RCT findings rather than perform a quantitative meta-analysis. Discussion: Across studies, LPD demonstrates comparable mortality and complication rates to OPD in high-volume centers, with consistent reductions intraoperative blood loss (IBL) and shorter recovery or length of stay (LOS). RPD shows more heterogeneous results: one large trial reported improved postoperative recovery, whereas the EUROPA trial identified higher rates of pancreatic fistula (POPF) and delayed gastric emptying (DGE) alongside significantly increased costs. Both LPD and RPD achieve oncological outcomes equivalent to OPD, and 3-year survival data confirm the long-term non-inferiority of LPD. However, operative time remains longer for all minimally invasive approaches, and conversion persists as a marker of technical difficulty and incomplete learning curve. Conclusions: Current RCT evidence indicates that MIPD is safe, feasible, and oncologically sound only when performed by surgeons who have surpassed the demanding learning curve within specialized, high-volume centers. The benefits, mainly reduced IBL and faster recovery, must be weighed against longer operative times, conversion risks, and substantially higher costs for RPD. MIPD should therefore be considered an advanced option rather than a universal standard, and its broader implementation requires structured training pathways, appropriate patient selection, and institutional readiness.