Junjie Wang†
Yakun Wu- Department of Hepatobiliary Surgery, Suining Central Hospital, Suining, Sichuan, China
Objective: Robotic distal pancreatectomy (RDP) is considered to offer certain advantages over traditional open distal pancreatectomy (ODP); however, high-quality evidence remains limited. This meta-analysis aimed to compare perioperative outcomes between RDP and ODP using data from propensity-score–matched studies.
Methods: A systematic literature search was performed using the PubMed, Cochrane Library, Embase, and Web of Science databases for studies comparing RDP and ODP. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.
Results: Seven studies with 1,526 patients were included (RDP group: 722 patients; ODP group: 804 patients). Compared with ODP, RDP was associated with a shorter hospital stay (MD −3.11 days; 95% CI, −4.45, −1.77), reduced blood loss (MD −163.38 mL; 95% CI, −212.08, −114.68), higher spleen preservation rates (OR 2.36, 95% CI, 1.06, 5.24) and lower surgical site infection (SSI) rates (OR 0.47, 95% CI 0.29, 0.76). No significant differences were found in 90-day mortality, overall morbidity, major complications, operative time, reoperation rates, postoperative pancreatic fistula, number of harvested lymph nodes, and R0 resection rates.
Conclusions: This meta-analysis suggests that RDP may have potential advantages over ODP, including reduced blood loss, shorter hospitalization, higher spleen preservation, and lower SSI rates. These potential benefits warrant confirmation in future randomized controlled trials.
Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251031280, PROSPERO CRD420251031280.
1 Introduction
Pancreatic surgery remains one of the most technically demanding abdominal procedures, associated with high postoperative morbidity (1, 2). Although advances in surgical techniques and perioperative management have markedly reduced postoperative mortality in high-volume centers, the incidence of complications after distal pancreatectomy (DP) remains as high as 40%–60% (3).
Compared with open surgery, minimally invasive approaches offer several advantages, including reduced surgical trauma, less intraoperative blood loss, and faster recovery, which may translate into improved perioperative outcomes (4, 5). Since Gagner et al. first reported minimally invasive DP in 1996, laparoscopic distal pancreatectomy (LDP) has gained increasing acceptance among pancreatic surgeons (6). However, conventional laparoscopy is limited by reduced instrument dexterity, two-dimensional visualization, and a steep learning curve (7). In contrast, robotic surgery maintains the advantages of minimally invasive techniques while providing three-dimensional visualization, enhanced instrument flexibility, tremor filtration, and a shorter learning curve (6, 7). Several cohort studies have compared robotic distal pancreatectomy (RDP) and open distal pancreatectomy (ODP) in terms of surgical outcomes (8–10). However, due to potential differences in baseline characteristics between study groups, results from these observational studies remain inconsistent and inconclusive (11). There is still a lack of high-quality evidence to confirm the advantages of robotic surgery in DP. To date, no randomized controlled trials (RCTs) have directly compared the efficacy of RDP and ODP. Propensity score matching (PSM) is a robust statistical approach that minimizes confounding by balancing baseline variables between groups, thereby reducing selection bias in observational studies (11, 12). Well-designed PSM studies have been shown to provide evidence comparable to that of RCTs (12, 13). In recent years, several PSM studies (2, 6, 14) have examined RDP vs. ODP, yet their findings remain heterogeneous.
Therefore, to provide more robust and high-quality evidence regarding the role of robotic surgery in DP, we conducted a comprehensive meta-analysis including only PSM studies to compare the short-term outcomes of RDP and ODP.
2 Methods
2.1 Search strategy
This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (15). The study protocol was registered with the PROSPERO database.
Two authors (JW and YL) independently conducted a comprehensive literature search using the EMBASE, Web of Science, PubMed, and Cochrane Library databases to identify potential studies published before February 25, 2025. The detailed search strategy is provided in Table 1. In addition, we checked the reference lists of the identified articles and related reviews to identify further eligible studies. No language restrictions were applied.
Table 1. Electronic search strategy.
2.2 Study selection
The inclusion criteria were: (1) Patient: adult patients who were undergoing DP; (2) Intervention: RDP; (3) Comparison: ODP; (4) Outcomes: Primary outcomes included 90-day mortality, overall complication, major complication, and length of stay. Secondary outcomes included blood loss, operative duration, spleen preservation, reoperation, postoperative pancreatic fistula (POPF), surgical site infection (SSI), number of harvested lymph nodes, and R1 resection; (5) Study type: PSM studies.
Reviews, letters, case reports, conference abstracts, single-arm studies, animal studies, and repeated publications were excluded.
2.3 Data extraction
The following data were extracted independently by two authors (JW and YL): author name, year of publication, country, study design, study population (sample size, sex, age, and body mass index), intraoperative information (blood loss, operative duration, and spleen preservation) and short-term outcomes. When data of interest were unavailable, the corresponding author was contacted to obtain the necessary data.
2.4 Quality assessment
The quality assessment was conducted independently by two authors (JW and YL) using the Newcastle-Ottawa Scale (NOS), which assigns a score on a 9-point scale. A score of ≥7 indicates high quality, and scores of 5–6 indicate moderate quality. Any discrepancies were resolved through discussion, with intervention by a third author (YW) whenever necessary.
2.5 Statistical analysis
In this study, statistical analyses were performed using the Review Manager software (version 5.3). Odds ratios (ORs) with corresponding 95% confidence intervals (CI) were calculated for qualitative variables and the mean difference (MD) for quantitative data. The I² statistic was used to quantify heterogeneity. A random-effects model was used if I² > 50%; otherwise, a fixed-effects model was employed (16). To explore the robustness of the results, we adopted the one-study exclusion method to evaluate the impact of each study on the overall effect size. Publication bias was assessed using Egger's test and funnel plot (if the number of included studies was more than 10) for primary outcomes. Statistical significance was set at p < 0.05.
3 Results
3.1 Study selection
The search yielded 2,451 records, of which 901 duplicates were excluded. After reviewing titles and abstracts, 1,519 studies were excluded, and the full-texts of the remaining 31 articles were evaluated. Finally, 7 studies (1–3, 5, 6, 14, 17) were included in the final analysis (Figure 1).
Figure 1. The PRISMA flowchart.
3.2 Study characteristics and quality assessment
Table 2 summarizes the characteristics of the 7 included studies (1–3, 5, 6, 14, 17). The studies were published between 2019 and 2024 and included 1,526 patients (RDP group: 722 patients; ODP group: 804 patients). The included patients were mainly from the United States, China, Italy, and Spain. All studies were considered of high quality, achieving a score of ≥7 based on the NOS. The relevant details of the PSM methods used in each included study are summarized in Table 3.
Table 2. Characteristics of the included studies.
Table 3. Details of the propensity score–matched methods.
3.3 Meta-analysis
3.3.1 90-day mortality
Three studies reported data on 90-day mortality. The combined results of the 3 studies showed that there was no significant difference between the RDP group and the ODP group regarding this outcome with low heterogeneity (OR 1.00, 95% CI 0.20, 4.99; Heterogeneity: I2 = 0%, P = 1.00) (Figure. 2A) (Table 4).
Figure 2. Comparison of primary outcomes between the two groups. (A) 90-day mortality, (B) overall complications, (C) major complications, and (D) length of stay.
Table 4. Outcomes of interest RDP vs. ODP.
3.3.2 Morbidity
Overall complication was reported in 3 studies. The pooled results suggested that the overall complication rate in the RDP group was comparable to that in ODP group (OR 0.90, 95% CI 0.55, 1.45, P = 0.65; I2 = 0%, P = 0.98) (Figure 2B).
3.3.3 Major complications
Combined data from 7 studies showed that the rates of major complications were comparable between the RDP and ODP groups (OR 1.25, 95% CI 0.88, 1.78; Heterogeneity: I2 = 0%, P = 0.45) (Figure 2C).
3.3.4 Length of stay
The length of the hospital stay was reported in 7 studies. According to the results of this meta-analysis, RDP significantly reduced the length of hospital stay (MD, −3.11 days; 95% CI, −4.45, −1.77, < 0.00001) (Figure 2D).
3.3.5 Blood loss
Six studies provided information on intraoperative blood loss. The combined results showed that RDP significantly reduced the amount of intraoperative blood loss (MD, −163.38 mL; 95% CI, −212.08, −114.68, <0.00001; I2 = 87%) (Figure 3A).
Figure 3. Comparison of secondary outcomes between the two groups. (A) intraoperative blood loss, (B) operative time, (C) R0 resection, and (D) number of lymph nodes harvested.
3.3.6 Operation time
The operation time was reported in 7 trials. The combined results showed that the operation time was similar between the RDP group and the ODP group (MD, 7.35 min; 95% CI, −25.37, 40.06, P = 0.66) (Figure 3B).
3.3.7 R0 resection
Five studies reported R0 resection, and the combined effect size suggested that the R0 resection rates were comparable between the two groups (OR 1.26, 95% CI 0.79, 2.00, P = 0.33; I2 = 41%) (Figure 3C).
3.3.8 Number of lymph nodes harvested
Three trials reported the number of lymph nodes harvested, and no significant difference was observed between the groups (MD, 2.34; 95% CI, −3.05, 7.73, P = 0.39; I2 = 57%) (Figure 3D).
3.3.9 Postoperative pancreatic fistula
Seven studies reported the POPF. There was no significant difference in the incidence of POPF (OR 0.97, 95% CI 0.74, 1.26, P = 0.80) (Figure 4A) between the RDP and ODP groups.
Figure 4. Comparison of secondary outcomes between the two groups. (A) postoperative pancreatic fistula, (B) surgical site infection, (C) spleen preservation rate, and (D) reoperation.
3.3.10 Surgical site infection
Three studies reported SSI. Compared with ODP, RDP significantly reduced SSI rate (OR 0.47, 95% CI 0.29, 0.76, P = 0.002), and the heterogeneity between studies was low (I2 = 40%, P = 0.19) (Figure 4B).
3.3.11 Spleen preservation rate
Spleen preservation rate was evaluated in 4 studies, and the pooled results showed RDP significantly improved the splenic preservation rate (OR 2.36, 95% CI 1.06, 5.24; heterogeneity: I2 = 66%, P = 0.03) (Figure 4C).
3.3.12 Reoperation
Reoperation was reported in 5 studies, and there was no significant difference in reoperation rates (OR 1.31, 95% CI 0.66, 2.62, P = 0.44) (Figure 4D) between the two groups.
3.4 Publication bias and sensitivity analysis
According to the Egger tests, and no significant publication bias was observed for overall complication (P = 0.651), major complications (P = 0.124), and length of stay (P = 0.258). Sensitivity analysis showed that no single study affected the overall effect size of the length of stay, 90-day mortality, overall complication, major complications, reoperation, operation time, blood loss, number of lymph nodes harvested, or R0 resection. The sensitivity analysis suggested that the total effect size of SSI changed significantly when the study by Weng et al. (17) (OR 0.61, 95% CI 0.32, 1.14, P = 0.12; I2 = 42%) was eliminated. The sensitivity analysis suggested that the total effect size of spleen preservation rate changed significantly when the study by lelpo et al. (1) (OR 2.42, 95% CI 0.94, 6.27, P = 0.07; I2 = 75%) or Weng et al. (17) (OR 1.58, 95% CI 0.84, 2.96, P = 0.16; I2 = 0%) was eliminated.
4 Discussion
Based on data from 1,526 patients across seven PSM studies, our meta-analysis demonstrated that RDP significantly reduced intraoperative blood loss, improved spleen preservation, lowered SSI rates, and shortened hospital stays compared with conventional ODP. In contrast, no significant differences were observed in 90-day mortality or morbidity. These findings provide important clinical evidence that RDP is not inferior to ODP in short-term safety and may offer additional perioperative benefits, assisting surgeons in selecting the optimal surgical approach.
In recent years, there has been increasing evidence that minimally invasive surgery, especially robotic surgery, can reduce surgical trauma and enhance postoperative recovery during major abdominal procedures such as colorectal surgery and gastrectomy (18–20). A RCT conducted by de Rooij et al. demonstrated that minimally invasive distal pancreatectomy (MIDP) promotes faster functional recovery and leads to improved quality of life compared with ODP (21). A meta-analysis by Manara et al. showed that robotic total gastrectomy significantly reduced intraoperative blood loss, time to first flatus, time to first ambulation, time to first liquid diet resumption, and hospital stay compared to open total gastrectomy (20). In addition, the study of Song et al. showed that robotic surgery could reduce the incidence of delayed gastric emptying (6). These improvements in postoperative recovery may contribute to shorter hospital stays, consistent with our finding that RDP was associated with a significantly shorter length of stay than ODP. A recent non-PSM study by Zhou et al. (9) also demonstrated that, compared with the conventional ODP group, the RDP group had less intraoperative blood loss, reduced transfusion requirements, and a shorter hospital stay. Postoperative complications are key indicators for evaluating the safety of surgical approaches, as they not only prolong hospitalization but also increase healthcare costs (22, 23). Weinberg et al. reported that patients with minor complications (Clavien–Dindo < III) experienced a median 17.1% increase in hospitalization costs, while those with major complications faced a 252% increase (23). Our study showed that the overall complication and major complication rates for RDP and ODP were comparable. The two groups were also comparable in terms of mortality. This is consistent with the results of the previous meta-analysis by Zhou et al. (7). Moreover, two RCTs have demonstrated that the postoperative complication rate of MIDP is comparable to that of ODP (21, 24). POPF remains one of the most common and clinically significant complications following DP (25). Reported incidences range from 24%–38% for all grades and 13%–17% for clinically relevant POPF (grade B and C) (25–27). The mortality of grade C POPF is as high as 30% (12). Considering the clinical value of POPF, we only analyzed the differences between the two surgical approaches in terms of clinically relevant POPF. Our study showed that the incidence of POPF in the robotic group (17.3%) was comparable to that in the open group (18.3%). SSI is the main cause of postoperative morbidity after major abdominal surgery. SSI greatly increases the financial burden and may require additional diagnostic tests and treatment (28). Several studies have suggested that robotic surgery may lower SSI risk (29, 30), likely due to smaller incisions and reduced tissue trauma (7). Our findings confirm the advantage of robotic surgery in decreasing SSI rates.
Spleen preservation is a key goal in DP for benign and low-grade malignant diseases (31, 32). However, maintaining splenic vasculature remains technically challenging during ODP (33). Robotic systems, with enhanced three-dimensional visualization, wristed instruments, and tremor reduction, facilitate these delicate dissections (7, 12). Several meta-analyses (34, 35) have shown that robotic surgery significantly improves spleen preservation compared to laparoscopic surgery. Our findings further confirm the benefits of RDP in preserving the spleen.
Complete tumor resection and adequate lymph node dissection are critical for the effective treatment of pancreatic tumors (36). Howard et al. demonstrated that R0 resection is associated with improved long-term survival (36). Furthermore, sufficient lymph node harvest is essential for accurate staging and prognosis (37). The number of lymph nodes acquired was an independent prognostic factor for patients. Wang et al. (37) reported that a minimum of 19 lymph nodes should be examined to ensure adequate staging in patients undergoing DP for pancreatic cancer. In our study, RDP and ODP were comparable in both R0 resection rates and the number of lymph nodes retrieved, consistent with the findings of Zhou et al. (7). Furthermore, a recent non-PSM study by Kamarajah et al. also demonstrated that there were no significant differences among RDP, LDP, and ODP in terms of R0 resection rates and the number of lymph nodes retrieved (38).
The high cost remains a major drawback of the robotic approach, which may be partly attributed to the additional instruments required for robotic surgery (2). Several retrospective studies (39, 40) have demonstrated that RDP is associated with significantly higher hospitalization costs compared with LDP. In contrast, RDP has been shown to reduce hospital costs relative to ODP (41, 42). With the increasing global adoption and technological maturation of robotic systems, the associated costs are expected to decline over time (39). However, because cost-effectiveness data were lacking in the included studies, further investigations are warranted to comprehensively assess the economic value of the robotic approach.
Our research has the following advantages. On the one hand, we conducted a comprehensive literature search, minimizing potential selection bias. On the other hand, we set strict inclusion criteria and included only PSM studies, enhancing the reliability of our results.
There are some limitations to this meta-analysis. First, the meta-analysis included a limited number of studies, some with small sample sizes. Second, all included studies were cohort studies, as no randomized controlled trials were available. Third, some outcomes (e.g., blood loss, length of hospital stay, operation time, number of lymph nodes harvested, and spleen preservation rate) exhibited high heterogeneity, which may be related to differences in surgeon experience, institutional volume, geographic region, and patient characteristics. In addition, the learning curve may be a critical factor influencing surgical outcomes. Chen et al. (3) reported that surgical performance could improve after overcoming the learning curve of RDP. However, even in high-volume centers, the learning curve for MIDP remains considerably long, requiring approximately 85 cases to achieve proficiency (43). Therefore, mastering MIDP still demands substantial practical experience. Due to the limited number of included studies, subgroup analyses could not be performed. Sensitivity analyses indicated that the results for blood loss, length of hospital stay, operation time, and number of lymph nodes harvested were robust. However, the spleen preservation rate was less stable, and further studies are needed to clarify this outcome. The heterogeneity of patient populations (benign lesions vs. malignant tumors) may influence the study results. Among the included studies, two (3, 6) enrolled only patients with malignant tumors, while five (1, 2, 5, 14, 17) included both benign and malignant cases. However, none provided separate analyses for benign and malignant cohorts. Therefore, we were unable to specifically evaluate the safety and efficacy of RDP in benign vs. malignant disease. Future studies are needed to investigate the outcomes of RDP in more defined patient populations. Apart from robotic surgery, laparoscopy represents another minimally invasive approach. However, the lack of comparative studies involving laparoscopic surgery limits the generalizability of our findings to broader clinical practice. Finally, although our findings suggest potential short-term benefits of RDP, the lack of long-term oncologic outcome data remains a major limitation. Further studies are warranted to comprehensively evaluate its long-term efficacy and oncologic safety.
In conclusion, this meta-analysis indicates that RDP achieves comparable short-term outcomes to ODP while significantly reducing intraoperative blood loss, enhancing splenic preservation, and lowering both SSI rates and length of hospital stay. Given that these findings are derived from non-RCTs, future high-quality RCTs with longer follow-up are warranted to further validate the potential benefits of RDP.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Author contributions
JW: Conceptualization, Data curation, Formal analysis, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YL: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YW: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that financial support was received for the research and/or publication of this article. This work was financially supported by Sichuan University-Suining School City cooperation special fund project (2023CDSN-17).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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Keywords: robotic distal pancreatectomy, open distal pancreatectomy, mortality, morbidity, meta-analysis
Citation: Wang J, Liu Y and Wu Y (2025) Comparison of the perioperative outcomes of robotic vs. open distal pancreatectomy: a meta-analysis of propensity-score-matched studies. Front. Surg. 12:1611773. doi: 10.3389/fsurg.2025.1611773
Received: 14 April 2025; Revised: 25 October 2025;
Accepted: 20 November 2025;
Published: 4 December 2025.
Edited by:
Shaocheng Lyu, Capital Medical University, ChinaReviewed by:
Matteo De Pastena, University of Verona, ItalyWenbo Zou, PLA Joint Logistic Support Force, China
Yulei Tao, University of Oklahoma Health Sciences Center, United States
Copyright: © 2025 Wang, Liu and Wu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Yakun Wu, eWFrdW53dTE5ODVAMTYzLmNvbQ==
†These authors have contributed equally to this work and share first authorship