Laparoscopic pancreatoduodenectomy: How far have we come and where are we headed?

Abstract

Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure has been described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon’s experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.

Keywords: Laparoscopic pancreatoduodenectomy; Roboticpancreatoduodenectomy; Minimally invasive pancreatoduodenectomy

Core tip: This editorial while discussing the evidence and controversies surrounding minimally invasive pancreatoduodenectomy, aims to update the reader about the highest level of evidence accumulated over the past few years. Pancreatoduodenectomy remains a demanding procedure even in the open approach and only few surgeons in high volume centres have published the outcomes following minimally invasive pancreatoduodenectomy. All these reports are retrospective data with inherent problems related to bias. To settle this issue, any randomized trial is unlikely to happen given the complexity of the cancer and patient selection for surgery in a resectable cancer. All these issues have been addressed in this editorial so that the pros and cons of minimally invasive pancreatoduodenectomy have been well conveyed and the reader takes home a balanced message.