Centers performing both laparoscopic and robot-assisted pancreatic surgery remain scarce; thus, limited comparative evidence exists. Only a handful of studies to date have attempted to compare the outcomes of RDP versus LDP [23–26]. Most of these studies demonstrated comparable outcomes between RDP and LDP, such as postoperative morbidity including POPF rates and LOHS. However, in general, RDP appeared to be associated with a longer operation time and increased rate of spleen preservation compared with LDP. In several studies, operative time was longer in RDP than in LDP. It can be explained by the longer docking time of the robotic system than the laparoscopic system and the burden of learning curve. Docking and undocking of the robot can be time-consuming especially for surgical teams during their learning phase. However, some large series reported shorter operation times with RDP compared with LDP after the learning curve [24]. The spleen should be preserved as much as possible in the case of benign or borderline diseases because spleen-preserving distal pancreatectomy offers patients other clinical benefits as well, such as lower morbidity, shorter hospitalization time, and prevention of life-threatening sepsis by splenectomy [27]. Others have demonstrated higher rates of POPF with splenectomy during distal pancreatectomy [28]. However, concomitant en bloc splenectomy is performed with distal pancreatectomy mainly for technical reasons, such as to make resection easier, shorten operative time, and minimize bleeding from dissecting splenic vessels. Spleen-preserving LDP is relatively time and labor consuming. RDP was associated with a significantly higher spleen-preserving rate, which resulted from the fact that the robotic approach was more effective at controlling splenic vessel bleeding due to the good flexibility of instruments and high-definition view in this system [29]. The cost-effectiveness of RDP is inconclusive, and the added benefit of the robot-assisted technique remains controversial to date.

Compared with LDP for pancreatic cancer, RDP appears capable of finer lymph node dissection and more radical dissection. Concerning pancreatic cancer, Daouadi et al. [24] retrospectively compared 94 LDP with 30 well-matched RDP patients. The oncological outcomes were superior for RDP, with higher rates of margin-negative resection and improved lymph node clearance. Nevertheless, randomized clinical trials demonstrating that these potential advantages correspond to an actual superiority of RDP over LDP are still lacking.

Although MIPD is still not universally practiced, it is now receiving more interest with increasing proficiency in the laparoscopic skills of surgeons and advances in technology, including surgical robotics. In recent years, a large number of single-institution series of MIPD have been performed, and a variety of studies have been reported. On these series comparing LPD and OPD, LPD seems advantageous over OPD in terms of estimated intraoperative blood loss, but it results in longer operative time. The rate of postoperative complications, POPF, including clinically relevant POPF, and delayed gastric emptying are comparable following OPD and LPD. However, the latter is associated with shorter LOHS (Table 29.2).