Single-institution experience of 500 consecutive pancreatoduodenectomies: case-matched outcomes of the da Vinci Xi robotic versus open procedures.

BACKGROUND

Pancreatoduodenectomy (PD) remains a technically demanding procedure with substantial postoperative morbidity. The robotic PD (R-PD) may offer advantages over open PD (O-PD), but its role is still under scrutiny. This study compared R-PD and O-PD within a mature, high-volume single-institution experience.

METHODS

From October 2008 to May 2024, 500 PDs were performed at our institution (388 O-PDs and 112 R-PDs since January 2018). The 112 R-PD cases were 1:1 case-matched with 112 O-PD cases to ensure comparability in terms of patient-related surgical risk (sex, age, BMI, ASA score), disease-related factors (histological diagnosis, and T stage) and surgeon-related expertise. Univariable and multivariable logistic regression analyses were performed to identify predictors of clinically relevant postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE).

RESULTS

Mean operative time was comparable between groups (389 vs 399 min, p = 0.315), with no conversions to open surgery for R-PD. Clinically relevant POPF occurred in 5.4% of R-PD patients vs 14.3% of O-PD (p = 0.025), and clinically relevant DGE in 21.4% vs 37.5% (p = 0.008). Median length of stay was shorter after R-PD (11 [8-22.75] vs 19.5 [13-27.5] days, p < 0.001). Rates of major complications (Clavien-Dindo ≥ III) were similar (15.2% for R-PD vs 14.3% for O-PD, p = 0.850). Thirty-day mortality was comparable (0.9% vs 1.8%, p = 0.561), while ninety-day mortality was 2.7% in both groups. Regression analysis showed that the robotic approach was associated with a lower risk of clinically relevant POPF in univariable analysis and a reduced risk of clinically relevant DGE in multivariable analysis.

CONCLUSIONS

When performed in centers with established robotic and pancreatic expertise, R-PD appears to be a safe alternative to open surgery, with an extremely low risk of conversion and potential advantages in perioperative recovery. These findings suggest that R-PD may be considered a first-line option in appropriately selected patients within experienced high-volume programs.