Minimally invasive pancreaticoduodenectomy: A comprehensive review

While an increasing number of open procedures are now routinely performed laparoscopically or robotically, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging operations in abdomen. The aim of this study is to evaluate the current status and development of MIPD. Embase, Medline, and PubMed databases were searched to identify studies up to and including Feb 2016 using the keywords “laparoscopic”, or “laparoscopy”, or “hand-assisted”, or “minimally invasive”, or “robotic”, or “da vinci” combined with “pancreaticoduodenectomy”, or “duodenopancreatectomy”, “Whipple”, or “pancreatic resection”. Articles written in English with more than 10 cases were included for review. Thirty-two articles representing 2209 patients were included for review. The weighted average operative time and intraoperative blood loss was 427.3 min and 289.4 mL respectively. A total of 375 patients required conversion to open pancreaticoduodenectomy (OPD), with an overall conversion rate of 17.8%. The postoperative severe complications (the Clavien–Dindo Classification ≥ III) occurred in 3.8%–33.0% patients, with an overall severe morbidity of 14.3%. Particularly, the overall incidence of clinically significant postoperative pancreatic fistula (POPF) was 8.0%. There were 26 perioperative death cases in total, with an overall postoperative mortality rate of 2.3%. The weighted average number of collected lymph nodes was 17.9, and R0 resection ranged from 60.0% to 100.0%. Comparisons between MIPD and OPD showed that MIPD increased operative time, decreased intraoperative blood loss and shortened the length of hospital stay, but the overall morbidity and mortality were comparable. MIPD is technically feasible and safe in highly selected patients and can offer acceptable oncological outcomes. But concerns such as long-term outcomes, cost-effectiveness analysis, and learning curve analysis should be fully demonstrated before the popularization of this challenging procedure.