Superiority of robotic over laparoscopic distal pancreatectomy in surgical outcomes evaluated by textbook outcome.

BACKGROUND

The comparative advantages of robot-assisted distal pancreatectomy (R-DP) over laparoscopic distal pancreatectomy (L-DP) remain to be fully established. This study aimed to evaluate the achievement of textbook outcomes (TO), a composite metric reflecting optimal perioperative results, in patients undergoing R-DP versus L-DP.

METHODS

A retrospective analysis was conducted in 180 patients who underwent minimally invasive distal pancreatectomy between February 2011 and July 2025, including 116 L-DP and 64 R-DP cases. TO was defined as the absence of conversion to open surgery, clinically relevant pancreatic fistula (CR-POPF), postpancreatectomy hemorrhage, Clavien-Dindo ≥ IIIa complications, and readmission. Logistic regression analyses were conducted to identify factors associated with TO and CR-POPF.

RESULTS

R-DP demonstrated a significantly lower conversion rate than L-DP (L-DP vs. R-DP: 10.3 vs. 1.6%, p = 0.034). Overall TO achievement was comparable between the two groups (L-DP vs. R-DP: 65.5 vs. 75.0%, p = 0.184), with a trend favoring R-DP was observed in spleen-preserving procedures (51.8 vs. 77.3%, p = 0.082). The robotic transpancreatic mattress suture for stump closure (TP method) significantly improved TO achievement (TP method vs. other procedures: 85.7 vs. 64.8%, p = 0.016) and reduced both conversion and CR-POPF rates. Multivariate analysis identified pancreatic thickness at the transection site ≥ 12 mm (OR 4.6) and conversion to open surgery (OR 4.9) as independent risk factors for CR-POPF. Among patients with pancreatic thickness ≥ 12 mm, R-DP significantly improved TO achievement compared with L-DP (L-DP vs. R-DP: 44.7 vs. 75.0%, p = 0.005).

CONCLUSIONS

R-DP significantly reduces conversion to open surgery while maintaining perioperative safety comparable to L-DP. Incorporation of the TP method into R-DP substantially improves TO achievement by reducing both conversion and CR-POPF, particularly in patients with a thick pancreas (≥ 12 mm). These findings support the clinical value of R-DP as an advantageous surgical strategy for optimizing perioperative outcomes in technically challenging cases.