Minimally Invasive Versus Open Pancreatoduodenectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: To compare perioperative outcomes of minimally invasive pancreatoduodenectomy (MIPD) to open pancreatoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs). Background: The wider adoption of MIPD has largely been fueled by observational studies rather than high-level evidence. Methods: We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science for RCTs comparing MIPD with OPD in adult patients with benign or malignant conditions requiring elective pancreatoduodenectomy. The primary outcomes were 90-day mortality, the comprehensive complication index, Clavien-Dindo grade ≥III complications, and hospital length of stay (LOS). Secondary outcomes included postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood loss, reoperation, operative time, and oncologic outcomes. Data were pooled as odds ratios or mean differences using a random-effects model. Risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach (PROSPERO ID: CRD42024592919). Results: Ten RCTs with a total of 1794 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, reoperation, readmission, or oncologic outcomes between MIPD and OPD. LOS was reduced for MIPD. No clinically relevant differences were found in the subgroup analyses of laparoscopic and robotic pancreatoduodenectomy. Certainty of evidence was moderate to low. Conclusions: MIPD showed no clinically relevant advantages over OPD. These findings were consistent both for the robotic and laparoscopic approach.