Ikenaga N, Kumamaru H, Inomata M, et al. Robotic Versus Open and Laparoscopic Pancreaticoduodenectomy: A Nationwide Matched Study in Japan. 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 2019–2023, 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 ≥20 PDs/year, yielding 20,898 OPD, 1,378 LPD, and 1,337 RPD cases. Propensity score matching generated 1,248 RPD–OPD pairs and 1,066 RPD–LPD pairs with balanced baseline characteristics.
RPD was associated with a significantly lower rate of severe postoperative complications (Clavien–Dindo ≥III) compared with OPD (22.2% vs. 25.9%; OR 0.82, 95% CI 0.68–0.98; 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).
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 (≥50 PDs/year).
Compared with LPD, RPD demonstrated a lower incidence of severe complications (23.0% vs. 27.6%; OR 0.78, 95% CI 0.64–0.95; 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.
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—at 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.
