Comparative Analysis of Open, Laparoscopic, and Robotic Pancreaticoduodenectomy: A Systematic Review of Randomized Controlled Trials

Abstract

Background and Objectives: Various publications have compared outcomes among open (OPDs), laparoscopic (LPDs), and robotic pancreaticoduodenectomies (RPDs); however, the number of randomized controlled trials (RCTs) remains limited. This study aims to conduct a systematic review and analyze the outcomes between these approaches from randomized controlled trials. Materials and Methods: We performed a systematic literature search across PubMed/MedLine, Cochrane Library, ClinicalTrials.gov, and Google Scholar to identify relevant RCTs. The systematic review was conducted using the reporting items for systematic reviews and network meta-analyses guidelines (PRISMA-NMA) and registered in Prospero (CRD420251024475). For statistical analysis R software (version 4.3.2) was used. Results: Eight RCTs involving 1416 patients (706 OPDs, 600 LPDs, 110 RPDs) were included. LPD had a significantly longer operative time than OPD, while RPD showed no significant difference compared to OPD. Blood loss was reduced in both minimally invasive approaches. LPD showed a higher R0 resection rate and lower pancreatic fistula rate, whereas RPD had the lowest mortality. No significant differences were observed in major complications, reoperation, or readmission. LPD shortened hospital stay; RPD showed no difference. Conclusions: Although open pancreaticoduodenectomy remains a well-established standard, both laparoscopic and robotic approaches offer safe alternatives with distinct advantages. LPD is associated with shorter hospital stay and lower pancreatic fistula rates, whereas RPD demonstrates the lowest mortality. The lack of direct randomized comparisons between LPD and RPD highlights the need for further head-to-head trials.

Keywords: laparoscopic pancreaticoduodenectomy; open pancreaticoduodenectomy; pancreatic cancer; pancreaticoduodenectomy; randomized controlled trials; robotic pancreaticoduodenectomy; systematic review.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart for study selection.

Figure 2

National Institute of Health Quality Assessment of Controlled Intervention Studies. Adapted from: Palanivelu et al. (2017) [15], Hilst et al. (2019) [11], Klotz et al. (2024) [21], Liu et al. (2024) [20], Poves et al. (2018) [16], Qin et al. (2024) [18], Wang et al. (2023) [17], Yoon et al. (2024) [19].

Figure 3

Forest plots of pairwise and network meta-analysis comparing outcomes of OPD, LPD, and RPD. Outcomes include operative time, blood loss, vascular resection, R0 resection rates, lymph node yield, Clavien–Dindo ≥ III complications, postoperative pancreatic fistula, bile leakage, hemorrhage, delayed gastric emptying, reoperation, readmission, 30- and 90-day mortality, and length of stay. Bottom right: conversion rates to open surgery from LPD and RPD. Values are presented as mean differences with 95% confidence intervals. Adapted from: Palanivelu et al. (2017) [15], Hilst et al. (2019) [11], Klotz et al. (2024) [21], Liu et al. (2024) [20], Poves et al. (2018) [16], Qin et al. (2024) [18], Wang et al. (2023) [17], Yoon et al. (2024) [19]. The black cubes represent the point estimates of each comparison, with their size indicating the weight of the data in the meta-analysis. Horizontal lines show 95% confidence intervals.

Figure 3

Forest plots of pairwise and network meta-analysis comparing outcomes of OPD, LPD, and RPD. Outcomes include operative time, blood loss, vascular resection, R0 resection rates, lymph node yield, Clavien–Dindo ≥ III complications, postoperative pancreatic fistula, bile leakage, hemorrhage, delayed gastric emptying, reoperation, readmission, 30- and 90-day mortality, and length of stay. Bottom right: conversion rates to open surgery from LPD and RPD. Values are presented as mean differences with 95% confidence intervals. Adapted from: Palanivelu et al. (2017) [15], Hilst et al. (2019) [11], Klotz et al. (2024) [21], Liu et al. (2024) [20], Poves et al. (2018) [16], Qin et al. (2024) [18], Wang et al. (2023) [17], Yoon et al. (2024) [19]. The black cubes represent the point estimates of each comparison, with their size indicating the weight of the data in the meta-analysis. Horizontal lines show 95% confidence intervals.