Ikenaga N, Kumamaru H, Inomata M, et al. . Ann Surg. December 2025.
This propensity matched study evaluated short-term outcomes of robotic pancreaticoduodenectomy (RPD) compared with open (OPD) and laparoscopic pancreaticoduodenectomy (LPD) using the Japanese National Clinical Database (NCD), which captures >95% of surgical procedures in that country.
Among 58,531 PDs performed 2019鈥�2023, 46,166 cases met eligibility criteria after excluding complex resections not suitable for robotic surgery. To ensure baseline institutional proficiency, analyses were restricted to centers performing 鈮�20 PDs/year, yielding 20,898 OPD, 1,378 LPD, and 1,337 RPD cases. Propensity score matching generated 1,248 RPD鈥揙PD pairs and 1,066 RPD鈥揕PD pairs with balanced baseline characteristics.
RPD was associated with a significantly lower rate of severe postoperative complications (Clavien鈥揇indo 鈮II) compared with OPD (22.2% vs. 25.9%; OR 0.82, 95% CI 0.68鈥�0.98; p = 0.031). Clinically relevant postoperative pancreatic fistula was reduced (19.3% vs. 24.5%; p = 0.002), and major blood loss was less frequent (4.8% vs. 12.7%; p <0.001). Median postoperative length of stay was 5 days shorter with RPD (19 days vs. 24 days; p <0.001). These benefits occurred despite substantially longer operative time (603 min. vs. 422 min.; p <0.001). In-hospital mortality was low and comparable (0.7% RPD vs. 0.8% OPD).聽
Notably, deep venous thrombosis (DVT) occurred more often after RPD (1.9% vs. 0.8%; OR 2.43; p = 0.016), and 30-day readmission was higher (4.3% vs. 2.2%; p = 0.004). Volume-stratified analyses showed that reductions in severe complications were concentrated in high-volume centers (鈮�50 PDs/year).
Compared with LPD, RPD demonstrated a lower incidence of severe complications (23.0% vs. 27.6%; OR 0.78, 95% CI 0.64鈥�0.95; p = 0.015) and clinically relevant pancreatic fistula (19.3% vs. 25.4%; p = 0.001). Conversion to open surgery was significantly reduced with RPD (3.5% vs 6.9%; OR 0.48; p <0.001), while blood loss >1,000 mL was similar (~5%). Operative time again favored LPD (612 vs. 524 min; p <0.001). Postoperative length of stay was marginally shorter (19 days vs. 20 days; p = 0.01), with no difference in mortality (~0.7%) or readmission.聽
DVT remained more frequent with RPD (2.1% vs 0.7%; OR 3.18; p = 0.005), particularly in lower-volume centers.
Overall, RPD was associated with improved short-term outcomes, including lower severe morbidity, fewer pancreatic fistulas, reduced blood loss, and shorter hospitalization, compared with both open and laparoscopic approaches鈥攁t the cost of longer operative times and a higher incidence of DVT.
Benefits were most pronounced in high-volume centers. The increased thromboembolic risk highlights the need for aggressive perioperative thromboprophylaxis and vigilance, particularly during prolonged robotic procedures. Long-term oncologic outcomes and cost-effectiveness were not assessed and remain key areas for future investigation.
