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Robotic pancreatic surgery: a slowly developing field.

HepatoBiliary Surg Nutr 2020;9(5):673-675 | http://dx.doi.org/10.21037/hbsn.2020.02.02 Robotic surgery has undergone rapid development over the last several decades and minimally invasive surgery has become the standard of care for many surgical specialties. Its adoption within the world of hepatobiliary and pancreas surgery has been tempered by the complexity of the procedures. Early reports showcased the feasibility of distal pancreatectomy and pancreaticoduodenectomy in a minimally invasive fashion and where followed by case series demonstrating its safety and efficacy (1,2). This has since been confirmed with large matched cohorts confirming at a minimum oncologic equivalence between minimally invasive pancreatic resections as compared to open procedures (3). Given the complexity of pancreatic surgery and the inherent limitations of laparoscopic surgery the robotic surgical platform has seen an exponential rise in attention with its role in minimally invasive pancreatic resections. Given this interest there have been two consensus guidelines published on minimally invasive pancreatic surgery demonstrating its growth within the field (4,5). The most recent publication reviewing this topic by Liu et al. composed a consensus document on robotic pancreatic surgery (4). The aim of this consensus statement was to review the safety, feasibility, efficacy and costeffectiveness of this approach in order to provide guidance and make recommendations for its future development. The committee, using the process established by the World Health Organization Handbook for Guideline Development, determined the topics of interest , prepared evidence-based documents and generated final recommendations. This was completed using the well-established and broadly used GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of evidencebased literature supporting each topic along with the Delphi process to obtain expert consensus on statements. With this methodology the committee proposed 19 topics that were analyzed producing 16 recommendations assessed by GRADE and 3 recommendations that lacked sufficient evidence-based literature to make formal GRADE recommendations but provided literature review and expert panel opinion on. The first 6 recommendations focused on robotic distal pancreatectomy (RDP) as it compares to both laparoscopic (LDP) and open distal pancreatectomy (ODP). The committee provided strong recommendation for the use of the robotic platform for this procedure regarding safety, feasibility and efficacy with a mix of moderate to low levels of evidence to support this. LDP has become standard practice and thus providing evidence-based support for RDP as at least equivalent to LDP is essential to its ongoing practice. The committee found since the first case presented in 2001 there has been a gradual accrual of case reports and more recent case series, meta-analyses and RCTs showing comparable outcomes and peri-operative measures of feasibility between RDP, LDP and ODP (6-8). They focused on the evidence that points towards similar lymph node harvest and surgical margin status as well as overall survival noted in the RDP vs. LDP and OPD. Evidence was also presented with commendation for RDP given its comparable postoperative outcomes and morbidity with decreased length of stay and intraoperative blood loss. Our own experience and data comparing robotic versus the laparoscopic approach for distal pancreatectomy reiterated the comparable outcomes in morbidity, mortality and Editorial