Perioperative Outcomes in Robotic, Laparoscopic and Open Distal Pancreatectomy: A Network Meta-Analysis and Meta-Regression

Background: Distal pancreatectomy is a potentially curative treatment for tumors of the pancreatic body and tail. Minimally invasive approaches, notably laparoscopic and robotic techniques, have gained increasing acceptance. This network meta-analysis aimed to compare perioperative outcomes of open, laparoscopic, and robotic distal pancreatectomy. Methods: A systematic search of MEDLINE, EMBASE, Web of Science, and Scopus identified studies comparing at least two approaches. Both Bayesian and frequentist network meta-analyses were conducted. Results: Sixty-seven studies including 18,113 patients met inclusion criteria. Surface under the cumulative ranking (SUCRA) analysis showed robotic surgery ranked first in 84.6% of measured parameters, accumulating 92.3% of total points. Laparoscopy showed intermediate results, while open surgery ranked lowest. Robotic, but not laparoscopic, surgery significantly reduced 30-day mortality (Odds Ratio [OR] = 0.37, 95% Confidence Interval [CI] 0.16–0.84) and lowered conversion rates compared with laparoscopy (OR = 0.30, 95% Credible Interval [CrI] 0.22–0.40). Both robotic and laparoscopic approaches, compared with open surgery, were associated with reduced blood loss (-304 mL and -273 mL), fewer transfusions (OR 0.25 and 0.30), smaller transfused volumes (-1.98 and -1.86 units), shorter ICU stays (-4.0 and -2.3 days), fewer reinterventions (OR 0.45 and 0.56), and shorter hospital stays (-8.8 and -6.9 days). Conclusions: Robotic distal pancreatectomy appears safe and confers significant advantages over open and laparoscopic surgery, including reduced 30-day mortality, lower conversion rates, and improved perioperative outcomes, when performed in appropriately equipped, high-volume settings.