Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

DOI: https://doi.org/10.46296/yc.v10i19.0959

PANCREATECTOMÍA ABIERTA FRENTE A ROBÓTICA COMO

TRATAMIENTO DEL CÁNCER DE PÁNCREAS: ANÁLISIS DE LOS

RESULTADOS QUIRÚRGICOS Y LA SEGURIDAD ONCOLÓGICA.

REVISIÓN SISTEMÁTICA

OPEN VS ROBOTIC PANCREATECTOMY AS TREATMENT FOR

PANCREATIC CANCER: ANALYSIS OF SURGICAL OUTCOMES AND

ONCOLOGICAL SAFETY. SYSTEMATIC REVIEW

1

2

Ayala-Velasco Jonathan Marcelo ; Cáceres-Aucatoma Freud ;

Ayala-Velasco Steven Leonardo ³

1

Graduate Program in Oncological Surgery, Directorate of Graduate Health Programs, Faculty

of Health Sciences, Universidad Indoamérica. Quito, Ecuador. Correo : jmav1989@hotmail.com.

ORCID ID: https://orcid.org/0000-0002-0581-5407

2

Graduate Program in Oncological Surgery, Directorate of Graduate Health Programs, Faculty

of Health Sciences, Universidad Indoamérica. Quito, Ecuador.

Correo: caceres905@puce.edu.ec ORCID ID: https://orcid.org/0000-0001-6177-3531

3

General Practitioner. Quito, Ecuador. Correo: stevenleonardoa@hotmail.com

Resumen

Antecedentes: El cáncer de páncreas presenta una elevada letalidad, y la resección con intención

curativa sigue siendo el componente central del tratamiento en la enfermedad resecable. La

cirugía robótica busca reducir el traumatismo perioperatorio sin comprometer la radicalidad

oncológica. Objetivo: Comparar los resultados perioperatorios, la seguridad y los resultados

oncológicos de la pancreatectomía robótica frente a la abierta en adultos con cáncer de páncreas.

Métodos: Se realizó una revisión sistemática siguiendo las directrices PRISMA 2020. Se

efectuaron búsquedas en PubMed/MEDLINE, Scopus, Web of Science, Embase y Cochrane

Library. Se incluyeron doce artículos que aportaban comparaciones directas o evidencia

complementaria sobre cirugía robótica, abierta o laparoscópica. El riesgo de sesgo se evaluó

mediante RoB 2, ROBINS-I y AMSTAR 2, según correspondiera, y la certeza de la evidencia por

desenlace se clasificó utilizando el sistema GRADE. Debido a la heterogeneidad, los gráficos de

bosque (*forest plots*) se consideraron exploratorios. Resultados: Se identificaron 1.134

registros, se cribaron 1.042 y se incluyeron 12 artículos. En la comparación entre

pancreatectomía distal robótica y abierta, la estancia hospitalaria se redujo en 3,11 días (DM -

3

9

,11; IC del 95%: -4,45 a -1,77; I²=76%) y la pérdida hemática en 163,38 ml (DM -163,38; IC del

5%: -212,08 a -114,68; I²=87%). No se observaron diferencias significativas en la resección R0

(

9

OR 1,27; IC del 95%: 0,62-2,60; I²=40%) ni en las complicaciones mayores (OR 1,27; IC del

5%: 0,88-1,81; I²=0%). El rendimiento ganglionar, la mortalidad a los 90 días, la recidiva y la

supervivencia global fueron comparables. Conclusiones: La pancreatectomía robótica reduce la

estancia hospitalaria y la pérdida hemática sin aumentar las complicaciones mayores. Los

resultados oncológicos disponibles son comparables a los de la cirugía abierta. La certeza de la

evidencia es moderada para los resultados perioperatorios y la resección R0, y baja para la

mortalidad y la supervivencia.

Palabras claves: Pancreatectomía; Cirugía robótica; Neoplasias pancreáticas; Complicaciones

posoperatorias; Márgenes quirúrgicos; Supervivencia.

Abstract

Background: Pancreatic cancer has high lethality, and curative-intent resection remains the

central component of treatment for resectable disease. Robotic surgery aims to reduce

perioperative injury without compromising oncological radicality. Objective: To compare

Información del manuscrito:

Fecha de recepción: 13 de mayo de 2026.

Fecha de aceptación: 20 de julio de 2026.

Fecha de publicación: 26 de agosto de 2026.

6

79

Ayala-Velasco et al. (2026)

perioperative outcomes, safety, and oncological outcomes of robotic versus open

pancreatectomy in adults with pancreatic cancer. Methods: A systematic review was conducted

according to PRISMA 2020. PubMed/MEDLINE, Scopus, Web of Science, Embase, and the

Cochrane Library were searched. Twelve articles providing direct comparisons or complementary

evidence on robotic, open, or laparoscopic surgery were included. Risk of bias was assessed with

RoB 2, ROBINS-I, and AMSTAR 2 as appropriate, and certainty by outcome was rated using

GRADE. Because of heterogeneity, forest plots were considered exploratory. Results: A total of

1

,134 records were identified, 1,042 were screened, and 12 articles were included. For robotic

versus open distal pancreatectomy, hospital stay was reduced by 3.11 days (MD -3.11; 95% CI -

.45 to -1.77; I²=76%) and blood loss by 163.38 mL (MD -163.38; 95% CI -212.08 to -114.68;

I²=87%). No significant differences were demonstrated in R0 resection (OR 1.27; 95% CI 0.62-

.60; I²=40%) or major complications (OR 1.27; 95% CI 0.88-1.81; I²=0%). Lymph-node yield, 90-

4

2

day mortality, recurrence, and overall survival were comparable. Conclusions: Robotic

pancreatectomy reduces hospital stay and blood loss without increasing major complications.

Available oncological outcomes are comparable with open surgery. Certainty is moderate for

perioperative outcomes and R0 resection, and low for mortality and survival.

Keywords: Pancreatectomy; Robotic surgery; Pancreatic neoplasms; Postoperative

complications; Surgical margins; Survival.

systemic treatment. R0 resection and

1

. Introduction

nodal assessment are fundamental

indicators, although survival also

depends on stage, response to

Pancreatic cancer remains among

the neoplasms with the highest

lethality due to its late diagnosis,

rapid progression, and therapeutic

systemic therapy, and the molecular

_a_g_g_r_e_s_s_i_v_e_n_e_s_s_o_f_t_h_e_t_u_m_o_r_.5-6

resistance.

Pancreatic

ductal

Open pancreatectomy has been the

conventional approach, but it

involves a wide incision, complex

dissection around the vascular and

biliary axes, potentially high blood

loss, and prolonged recovery.

Robotic surgery provides three-

adenocarcinoma represents the

predominant histological form, and

even with multimodal treatment,

survival continues to be conditioned

by tumor biology and the early

presence of microscopic disease.

Curative-intent surgical resection

dimensional

vision,

articulated

remains indispensable in patients

_w_i_t_h_r_e_s_e_c_t_a_b_l_e_d_i_s_e_a_s_e_.1^-⁴

instruments, tremor filtration, and

greater precision in deep anatomical

spaces. Comparative studies and

meta-analyses have reported less

bleeding and shorter hospital stay,

The

oncological

quality

of

pancreatectomy is assessed through

the achievement of tumor-free

margins,

adequate

although with longer operative time

lymphadenectomy, and the absence

of severe complications that delay

_o_r_h_i_g_h_e_r_c_o_s_t_i_n_c_e_r_t_a_i_n_s_e_t_t_i_n_g_s_.7-14

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

Recent randomized trials and

multicenter studies have

resection, nodal yield, recurrence,

and survival (O)?

strengthened the evaluation of

minimally invasive and robotic

surgery. In distal pancreatectomy

The general objective was to

compare the surgical safety and

oncological outcomes of robotic

versus open pancreatectomy in

adults with pancreatic cancer. The

specific objectives were: 1) to

and

pancreaticoduodenectomy,

these studies suggest that reduced

perioperative invasiveness can be

achieved without compromising

margins, nodal yield, or early

outcomes; however, the magnitude

of benefit depends on patient

selection, the procedure, and

institutional experience. ¹⁵^-¹⁹

characterize

populations,

comparators

the

designs,

and

procedures,

of

the

included

evidence; 2) to compare blood loss,

hospital stay, major complications,

and early mortality; 3) to compare R0

resection, nodal yield, recurrence,

recurrence-free survival, and overall

survival; and 4) to assess risk of bias,

Long-term

oncological

safety

remains the central issue. National

cohorts and adjusted studies report

comparable survival and recurrence

between robotic and open surgery,

GRADE

certainty,

and

the

consistency of effects represented in

the forest plots.

but

residual

confounding,

heterogeneity of definitions, and

limited representation of lower-

volume centers persist. ²⁰^-²³

2

. Methods

Design and reporting guidance

PICO question: In adults with

resectable pancreatic cancer (P),

does robotic pancreatectomy (I),

compared with open pancreatectomy

A systematic review was conducted

following

the

PRISMA

2020

statement. ²⁴The PICO question and

outcomes were defined before

synthesis: adults with resectable

pancreatic cancer; intervention,

(

C), reduce blood loss, hospital stay,

major complications, and mortality

while maintaining equivalent

oncological outcomes in R0

robotic pancreatectomy; main

comparator, open pancreatectomy;

6

81

Ayala-Velasco et al. (2026)

and perioperative and oncological

outcomes.

not replace the main comparator.

Case reports, letters, editorials,

comparator-free

publications

outcomes

series,

and

Information sources and search

strategy

without

were

relevant

excluded.

A structured search was performed

in PubMed/MEDLINE, Scopus, Web

of Science, Embase, and the

Cochrane Library, with no start-date

Systematic

analyses

reviews

were

or meta-

identified

as

secondary sources and were used

only for context or for the exploratory

forest plots based on aggregate data.

restriction.

MeSH

terms

and

keywords related to pancreatic

Selection,

variables

extraction,

and

cancer,

pancreatic

ductal

robotic

adenocarcinoma,

pancreatectomy,

surgery, open

robot-assisted

pancreatectomy,

Two

reviewers

independently

assessed titles, abstracts, and full

texts; discrepancies were resolved

by consensus. Author, year, country,

design, sample size, available

clinical characteristics, type of

pancreatectomy, comparator, blood

loss, operative time, conversion,

length of stay, major complications,

mortality, R0, nodes examined,

recurrence, and survival were

extracted. When sociodemographic

variables were not uniformly reported

or were unavailable by group, they

were described qualitatively and no

pooled estimates were generated.

pancreaticoduodenectomy,

distal

pancreatectomy, surgical outcomes,

oncologic outcomes, postoperative

complications,

margin

status,

recurrence, and survival were

combined. The strategy proposed for

PubMed/MEDLINE is presented in

Annex 1.

Eligibility criteria

Studies in adults undergoing

pancreatic resection for cancer that

compared robotic surgery with open

surgery,

or

that

provided

on

complementary

evidence

Risk of bias and certainty of

evidence

technical and oncological safety,

were included. Direct robotic-open

comparisons

were

prioritized.

The randomized trial was assessed

with RoB 2 and the non-randomized

Robotic-laparoscopic studies were

considered indirect evidence and did

25-26

studies with ROBINS-I.

The

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

secondary reviews used for context

were assessed with AMSTAR 2. ²⁸

The certainty of evidence was rated

of substantial inconsistency. ¹²^,²⁹

A

global meta-analysis of the 12

articles was not performed.

by

outcome

using

risk

GRADE,

of bias,

3

. Results and discussion

considering

inconsistency,

indirectness,

Study selection

imprecision, and publication bias. ²⁷

A total of 1,128 records were

identified in databases and 6 through

manual searching. After removing

duplicates, 1,042 records were

screened by title and abstract; 756

were excluded and 286 full texts

were assessed. Of these, 274 texts

were excluded for non-relevant

Synthesis and forest-plot analysis

The main synthesis was narrative

because of the heterogeneity of

procedures,

comparators,

and

definitions. Exploratory forest plots

were presented for hospital stay,

blood loss, R0 resection, and major

complications, based on comparable

aggregate data for robotic versus

open distal pancreatectomy. The

pooled estimate, its 95% confidence

interval, statistical significance, and I²

heterogeneity were interpreted; high

I² values were considered indicative

comparator,

population,

non-matching

insufficient data,

absence of relevant outcomes, or

duplication. Finally, 12 articles were

included. The process is presented in

Figure 1 and was reported in

_a_c_c_o_r_d_a_n_c_e_w_i_t_h_P_R_I_S_M_A₂₀₂₀_.24

Figure 1. PRISMA flow diagram for the systematic review. Source: created by the authors

6

83

Ayala-Velasco et al. (2026)

included.

comparisons supported the main

conclusions, while robotic-

laparoscopic studies were used as

indirect evidence. Age, sex,

and neoadjuvant

were not reported

so was not

Direct

robotic-open

Characteristics of the evidence

and of the included populations

The 12 articles included adults

undergoing distal pancreatectomy,

pancreaticoduodenectomy, or total

comorbidity,

treatment

pancreatectomy.

cohorts and

Retrospective

propensity-score-

uniformly,

it

matched analyses predominated;

methodologically valid to generate a

randomized

databases,

evidence,

and

national

pooled sociodemographic synthesis.

supporting

7-23,30-44

secondary sources were also

Table 1. Main characteristics of the 12 included articles

No.

Study

Design/comparison

Population

Main results

Applicability

R0 73% vs 69%; nodes

2

58 adults with

22 vs 23; severe adverse

Partially direct: MIDP

includes laparoscopy and

robotic surgery.

Korrel et

al., 2023

Multicenter non-inferiority

RCT; MIDP vs ODP.

resectable

pancreatic cancer of

the body/tail.

1

events 18% vs 22%; no

differences in recurrence

or overall survival.

16

Longer operative time

with RDP, but less

bleeding and faster

recovery; grade III-IV

complications 11% in

both groups; equivalent

survival.

Bencini et

al., 2024

Retrospective cohort with

PSM; RDP vs ODP.

79 patients; 50 after

matching (25/25).

2

3

Direct.

8

Shorter stay (MD -3.11

days), less blood loss

(MD -163 mL), greater

Systematic review/meta-

analysis of PSM studies;

RDP vs ODP.

7 studies; 1,526

patients (RDP 722;

ODP 804).

Wang et

al., 2025

splenic preservation, and

lower surgical site

infection; no differences

in R0, nodes, or 90-day

mortality.

Direct for pooled

quantitative synthesis.

12

Less bleeding and shorter

stay with RPD;

comparable nodal yield,

R0 margins, recurrence-

free survival, and overall

survival.

2

36 patients after

Takagi et

al., 2026

Retrospective PSM

cohort; RPD vs OPD.

Direct for

pancreaticoduodenectomy.

4

5

6

PSM (118/118) at a

high-volume center.

3

0

Fewer perioperative

complications, VTE, and

transfusions; slightly

shorter stay; higher

hospital cost; did not

report margins, nodes,

recurrence, or survival.

Less blood loss and

greater splenic

preservation with RDP;

similar complications; no

complete oncological

outcomes.

8

86 patients with

Huang et

NIS database; robotic vs

laparoscopic distal.

pancreatic cancer;

239 robotic and 647

laparoscopic.

Indirect: does not compare

with open surgery.

3

4

al., 2024

102 patients

Indirect: laparoscopic

comparator and mixed

population.

Chen P. et

Retrospective cohort;

RDP vs LDP.

(48/54), benign and

low-grade malignant

lesions.

3

5

al., 2022

Less bleeding, greater

splenic preservation, and

lower conversion with

RDP; higher R0 and

nodal yield; comparable

safety.

Shorter stay with RTP;

comparable 90-day

mortality, nodal yield,

positive margin rate, and

overall survival.

1

,016 patients

Chen J.W.

et al.,

2

International

retrospective cohort;

RDP vs LDP.

(274/742) with

7

8

Indirect for the main PICO.

resectable

pancreatic cancer.

36

023

3,635 patients

(188/3,447) with

McKean et

National Cancer

Database; RTP vs OTP.

Direct for total

pancreatectomy.

adenocarcinoma

undergoing total

pancreatectomy.

31

al., 2025

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

No.

Study

Design/comparison

Population

Main results

Less bleeding and

greater splenic

preservation with RDP;

longer operative time and

higher costs; similar

complications.

Applicability

6

0 patients (30/30),

Di Franco

et al.,

Matched retrospective

cohort; RDP vs LDP.

benign and low-

grade malignant

lesions.

9

Indirect.

37

022

2

Lower conversion,

greater splenic

7

55 patients

preservation, and less

bleeding with RDP; in the

oncological subgroup,

comparable R0 and nodal

yield.

Lof et al.,

2

Multicenter cohort; RDP

vs LDP.

(221/534), benign,

premalignant, and

malignant lesions.

10

Indirect.

38

021

Greater splenic

preservation, less

bleeding, and lower

conversion with RDP;

similar R0 margins and

nodal yield in the

malignant subgroup.

Less bleeding, greater

splenic preservation, and

lower conversion with

RDP; similar safety;

higher cost.

1

42 patients

Jiang et

al., 2022

Retrospective cohort;

RDP vs LDP.

1

2

(62/80), single

center.

Indirect.

3

9

Prospective comparative

and cost-effectiveness

study; RDP vs LDP.

Souche et

1

62 patients (31/31).

4

0

al., 2019

selection, residual confounding, and

incomplete measurement. GRADE

certainty was moderate for hospital

stay, blood loss, R0 resection, and

major complications; low for 90-day

Risk of bias and certainty of

evidence

The randomized trial showed low risk

of bias or some concerns depending

on the domain, whereas the

mortality; and low to moderate for

observational

studies

risk

showed

from

_o_v_e_r_a_l_l_s_u_r_v_i_v_a_l_.25-29

moderate-to-serious

Table 2. Risk-of-bias assessment of the included articles

Overall

judgment

Study

Korrel 2023

Bencini 2024

Wang 2025¹²

Tool

Main justification

Randomized, multicenter trial, but the MIDP group combines

laparoscopy and robotic surgery, introducing indirectness for a strictly

robotic-versus-open comparison.

Retrospective design and small sample; PSM reduces, but does not

eliminate, residual confounding.

Meta-analysis of PSM studies with substantial heterogeneity in

continuous outcomes; useful as an aggregate source, not as a primary

study.

Some

RoB 2

concerns

Moderate

ROBINS-I

AMSTAR/GRADE

for synthesis

Moderate

PSM and high-volume center; possible residual confounding and

extrapolation by procedure type.

National database with statistical adjustment; limited by surgical

variables and incomplete clinical detail.

Takagi 2026³⁰

ROBINS-I

Moderate

McKean 2025³¹

Administrative database, laparoscopic comparator, and absence of

complete oncological outcomes.

Single center, retrospective, indirect comparator, and mixed population.

Multicenter and large, but laparoscopic comparator; indirectness for the

main PICO.

Huang 2024

ROBINS-I

Serious

Moderate

Chen P. 2022

Chen J.W. 2023

Small sample, indirect comparator, and cost focus; limited oncological

outcomes.

Multicenter; laparoscopic comparator; possible selection by center

experience.

Single center, retrospective, and mixed cohort; imprecision due to

sample size.

Prospective, but small sample and laparoscopic comparator; cost results

not generalizable.

Di Franco 2022

Lof 2021

ROBINS-I

Serious

Moderate

Serious

Jiang 2022

Souche 2019

Moderate

6

85

Ayala-Velasco et al. (2026)

was performed by outcome, in

accordance with GRADE. ²⁷

GRADE rating by included study

Table 3 presents the methodological

traceability by study. The final rating

Table 3. GRADE rating of the 12 included articles

Design/data

source

Risk of

bias

Other GRADE

domains

Study

Applicability

Certainty

Justification

High for MIDP vs open;

moderate when

Mild indirectness due to

MIDP; no significant

imprecision.

Korrel et al.,

023

Not

serious

High to

moderate

Multicenter RCT

Partially direct

2

interpreted strictly as

robotic versus open.

Direct observational

evidence, useful for

safety, but limited by

sample size.

Consistent effects for

bleeding and length of

stay, although with high

heterogeneity.

High-volume center and

PSM strengthen the

evidence, but residual

confounding persists.

Large size and

Imprecision due to

small sample;

inconsistency not

serious.

Serious heterogeneity

in continuous variables;

no significant

Bencini et al.,

024

PSM cohort

Direct

Serious

Low

2

Wang

PSM meta-

analysis

Moderate

12

2

025

indirectness.

Mild indirectness by

procedure; imprecision

not serious.

Takagi

Low to

moderate

PSM cohort

30

2

026

Mild indirectness due to

total pancreatectomy;

no relevant imprecision

from sample size.

Adjusted

national

database

McKean

Low to

moderate

oncological outcomes,

but limited by

administrative database.

31

2

025

Serious indirectness:

does not compare with

open surgery;

oncological outcomes

absent.

Serious indirectness

and imprecision; mixed

population.

Serious indirectness

due to laparoscopic

comparator;

Provides indirect

perioperative safety data,

not oncological radicality.

Huang et al.,

024

NIS database

Retrospective

Indirect

Serious

Low

2

Laparoscopic comparator

and incomplete

Chen P. et

al., 2022

Very low to

low

Indirect

Serious

oncological results.

Useful for technical

quality and resection, not

for direct comparison with

open surgery.

Small sample and

economic focus; indirect

comparator.

Chen J.W. et

al., 2023

Multicenter

cohort

Low

imprecision not serious.

Serious indirectness

and imprecision; limited

oncological outcomes.

Di Franco et

al., 2022

Matched

retrospective

Very low to

low

Indirect

Serious

Provides complementary

technical evidence versus

laparoscopy.

Lof et al.,

Multicenter

cohort

Serious indirectness;

imprecision not serious.

Low

2021

Serious indirectness

and imprecision; single

center.

Jiang et al.,

022

Very low to

low

Mixed cohort and limited

size.

Retrospective

2

Serious indirectness

and imprecision;

contextual economic

results.

Prospective, but small

and with a laparoscopic

comparator.

Souche et

al., 2019

Comparative

prospective

Indirect

Serious

Low

Summary of findings by outcome

Table 4 summarizes the direction of effect, heterogeneity, and GRADE certainty

for the priority outcomes.

Table 4. Summary of findings and GRADE certainty by main outcome

GRADE

certainty

Outcome

Available evidence

Summary effect

Heterogeneity

Interpretation

MD -3.11 days

(95% CI -4.45 to -

1.77); favors

Significant difference;

variable magnitude

across studies.

7

PSM studies; 1,526

Hospital stay

I²=76% (high).

Moderate

patients.

robotic surgery.

MD -163.38 mL

6

PSM studies;

Significant difference;

substantial

heterogeneity.

(

-

95% CI -212.08 to

114.68); favors

Blood loss

approximately 1,476

patients.

I²=87% (high).

Moderate

robotic surgery.

OR 1.27 (95% CI

0.62-2.60).

OR 1.27 (95% CI

0.88-1.81).

5

studies, RDP vs

No significant difference;

comparable radicality.

R0 resection

I²=40% (moderate).

I²=0% (none).

Moderate

Low

ODP.

7 PSM studies, RDP

vs ODP.

Direct studies and

adjusted databases.

Major

complications

No significant difference.

No significant

differences.

Not uniformly

poolable.

Infrequent events and

imprecise intervals.

90-day mortality

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

GRADE

certainty

Outcome

Available evidence

Summary effect

Heterogeneity

Interpretation

HR around 1; no

consistent

difference.

Trial, cohorts, and

adjusted registries.

Heterogeneous

follow-up.

Low to

moderate

Comparable results, with

residual uncertainty.

Overall survival

Perioperative outcomes

experience

and

standardized

protocols. Results from indirect

comparisons were used to describe

technical performance, not to

establish primary equivalence.

Direct evidence favored robotic

surgery for blood loss and hospital

stay. In the pooled analysis of distal

pancreatectomy,

the

mean

difference was -163.38 mL for

bleeding and -3.11 days for length of

stay. No statistically significant

increase in major complications,

reintervention, or 90-day mortality

was observed. In comparisons with

laparoscopy, robotic surgery showed

lower conversion and greater splenic

preservation, but these findings were

considered complementary. ⁸^-¹⁹^,³⁰^-⁴⁴

Interpretation of the forest plots

The forest plots represent only

outcomes

with

comparable

aggregate data for robotic versus

open distal pancreatectomy. The

diamond summarizes the pooled

effect; a mean difference whose

interval does not cross 0 indicates a

statistically significant difference,

whereas an odds ratio whose interval

does not cross 1 indicates a

Oncological outcomes

significant

difference.

I²

R0 margins and nodal yield were

comparable between robotic and

open surgery. Adjusted cohorts and

national registries showed no

consistent differences in recurrence,

recurrence-free survival, or overall

survival. Interpretation was more

uncertain when follow-up was short,

data came from administrative

heterogeneity quantifies the variation

between studies not attributable to

chance. ¹²^,²⁹

databases, or the comparison was

_i_n_d_i_r_e_c_t_.1⁶^,²⁰^-²³^,³⁰^-³³^,⁴⁵^-⁴⁶

Clinical applicability was

concentrated in centers with robotic

6

87

Ayala-Velasco et al. (2026)

Figure 2. Exploratory forest plot of hospital stay: robotic versus open distal pancreatectomy.

Source: created by the authors from the pooled data of Wang et al. ¹²

pancreatectomy. Heterogeneity was

Figure 2 showed a shorter stay with

high (I²=76%), which requires

robotic surgery: MD -3.11 days (95%

considering differences in discharge

CI -4.45 to -1.77). The interval did not

protocols, centers, and patient

cross 0, so the effect was statistically

selection. ¹²

significant and favored robotic distal

Figure 3. Exploratory forest plot of intraoperative blood loss: robotic versus open distal

pancreatectomy. Source: created by the authors from the pooled data of Wang et al. ¹²

Figure 3 showed less blood loss with

robotic surgery: MD -163.38 mL

interval did not cross 0, and the effect

significantly favored robotic surgery.

Heterogeneity was high (I²=87%), so

(95% CI -212.08 to -114.68). The

6

88

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

the exact magnitude of the benefit

may vary across institutions. ¹²

Figure 4. Exploratory forest plot of R0 resection: robotic versus open distal pancreatectomy.

Source: created by the authors from the pooled data of Wang et al. ¹²

Figure 4 showed an OR of 1.27 for

R0 resection (95% CI 0.62-2.60;

I²=40%). Because the interval

crossed 1, there was no statistically

significant difference; the result

indicates comparable oncological

radicality and does not demonstrate

superiority of either approach. ¹²

Figure 5. Exploratory forest plot of major complications: robotic versus open distal

pancreatectomy. Source: created by the authors from the pooled data of Wang et al. ¹²

6

89

Ayala-Velasco et al. (2026)

Figure 5 showed an OR of 1.27 for

major complications (95% CI 0.88-

Perioperative

outcomes

and

physiological explanation

1

.81; I²=0%). The interval crossed 1,

so no significant difference was

demonstrated. The null

The 163.38 mL reduction in blood

loss is consistent with the enhanced

three-dimensional vision, instrument

articulation, and precise dissection

around the splenic, mesenteric, and

portal vessels. From a surgical-

heterogeneity indicates consistency

among the included studies for this

outcome. ¹²

Discussion

anatomy

standpoint,

facilitate

these

the

advantages

Correspondence between the

evidence and the populations

studied

identification of avascular planes and

control of small branches. From a

physiological

standpoint,

less

bleeding reduces the need for fluid

replacement, hemodilution, and

exposure to transfusion; the latter

can produce immunomodulation and

transiently alter the inflammatory and

cellular response. ¹²^,⁶⁴

This review identified clinically

relevant heterogeneous

evidence. The studies encompassed

distal pancreatectomy,

but

pancreaticoduodenectomy, and total

pancreatectomy, with randomized

designs, adjusted cohorts, national

registries, and indirect comparisons

with laparoscopy. This diversity

broadens applicability but precludes

assuming that an effect observed in

a distal resection is identical in a

pancreaticoduodenectomy. Recent

meta-analyses agree that robotic

surgery can achieve favorable

The 3.11-day reduction in hospital

stay may be related to less

abdominal wall injury and less tissue

manipulation. The response to

surgical trauma activates the

hypothalamic-pituitary-adrenal axis,

catecholamines, cortisol, insulin

resistance,

and

inflammatory

mediators. Lower injury, combined

with multimodal analgesia and early

mobilization and feeding, favors

functional recovery. However, the

I²=76% heterogeneity indicates that

perioperative

outcomes

and

comparable oncological radicality,

although certainty decreases when

different procedures and designs are

combined. ⁴⁵^-⁴⁷

recovery

protocols,

discharge

6

90

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Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

criteria, and institutional organization

also influenced the effect. ⁶¹^-⁶³

and the principles of tumor handling.

5-6,20-23

The absence of

a

significant

The similarity in recurrence and

survival also reflects that the surgical

approach is only one of the

difference in major complications

does not contradict the technical

benefits. Pancreatic fistula depends

largely on gland texture, duct

determinants

of

prognosis.

Pancreatic ductal adenocarcinoma

frequently shows alterations in

KRAS, TP53, CDKN2A, and SMAD4,

diameter,

secretion,

perfusion,

and

exocrine

or

closure

anastomotic technique; delayed

gastric emptying and post-

molecular

desmoplastic stroma, and perineural

invasion; furthermore, cellular

heterogeneity,

pancreatectomy hemorrhage have

their own mechanisms. Therefore,

the robotic platform can reduce

dissemination may begin before the

lesion is clinically evident. These

features explain why a technically

less invasive surgery does not

necessarily modify the natural history

of the tumor on its own, and why

bleeding

and

trauma

without

eliminating

complications

determined by pancreatic biology.

The ISGPS and Clavien-Dindo

definitions are essential for valid

systemic treatment remains decisive.

_c_o_m_p_a_r_i_s_o_n_s_.5⁷^-⁶⁰

2-4,65-67

Oncological

outcomes

and

Risk of bias, certainty, and

applicability

relationship with tumor biology

The plots and direct studies showed

no deterioration in R0 resection,

nodal yield, or survival. The OR for

R0 was 1.27, but the 0.62-2.60

interval crossed unity; therefore, it

demonstrates neither superiority nor

inferiority. This equivalence is

plausible when dissection respects

the same anatomical planes, the

recommended lymphadenectomy,

The moderate certainty for length of

stay,

bleeding,

R0,

and

complications is supported by the

directional consistency of several

studies,

but

is reduced

by

heterogeneity and the predominance

of observational designs. Ninety-day

mortality and survival retained low or

low-to-moderate certainty due to

infrequent events, uneven follow-up,

6

91

Ayala-Velasco et al. (2026)

and residual confounding. The forest

plots should be interpreted as

exploratory estimates for the

studies, the inclusion of different

pancreatic procedures, the presence

of laparoscopic comparators, non-

uniform definitions, and incomplete

availability of sociodemographic

variables by group. The forest plots

were derived from aggregate data for

a comparable subset and do not

represent an independent meta-

analysis of the 12 articles. The high

heterogeneity in length of stay and

bleeding, the possible selection of

patients at expert centers, and

comparable subset, not as

a

definitive synthesis of all procedures.

Generalization requires considering

institutional volume and the learning

curve. Structured training programs

shorten the initial phase, but

published results frequently come

from expert centers. In addition,

acquisition,

maintenance,

costs

and

can

operating-room-time

uneven

follow-up

reduce

exceed the savings derived from

shorter stay or fewer complications;

efficiency depends on volume,

platform utilization, and the health

care system. ⁴⁸^-⁵⁶

generalizability. Individual-level data

were not available to adjust for age,

frailty, neoadjuvant treatment, stage,

pancreatic texture, or institutional

volume.

Taken together, the evidence

supports robotic pancreatectomy as

an alternative in centers with

4

. Conclusions

appropriate patient selection,

a

1. The included evidence was

heterogeneous and consisted mainly

of observational studies, with

trained team, and the capacity to

uphold oncological principles. It does

not justify indiscriminately replacing

open surgery, especially in scenarios

of complex vascular invasion, lack of

experience, or limited resources.

representation

of

distal

pancreatectomy,

pancreaticoduodenectomy, and total

pancreatectomy.

Limitations

2. Robotic pancreatectomy reduced

hospital stay and intraoperative

blood loss compared with open

surgery.

The review was limited by the

predominance

of

observational

6

92

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

3

. Robotic pancreatectomy did not

cancer. Nat Rev Dis Primers.

016;2:16022.

doi:10.1038/nrdp.2016.22.

2

increase major complications or early

mortality, and showed comparable

results in R0 resection, nodal yield,

recurrence, and survival.

5

. Howard TJ, Krug JE, Yu J,

Zyromski NJ, Schmidt CM,

Jacobson LE, et al. A margin-

negative

R0

resection

4

. The certainty of evidence was

accomplished with minimal

postoperative complications is

the surgeon's contribution to

long-term

pancreatic

Gastrointest

moderate for hospital stay, blood

loss, R0 resection, and major

complications, and low or low-to-

moderate for mortality and survival.

survival

cancer.

in

J

Surg.

2

006;10(10):1338-1345.

doi:10.1016/j.gassur.2006.09.

08.

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Open vs robotic pancreatectomy as treatment for pancreatic cancer: analysis of surgical outcomes and oncological safety.

Systematic review.

ANNEXES

Annex 1. Proposed PubMed/MEDLINE search strategy

The following strategy is proposed to reproduce the search in PubMed/MEDLINE.

It may be adapted according to the final closing date of the review and the

journal's editorial requirements. Applying language filters in the initial search is

not recommended, in order to reduce selection bias; any subsequent restriction

should be documented at the eligibility stage.

Database: PubMed/MEDLINE.

Main fields: MeSH terms and title/abstract (tiab).

Search concepts: pancreatic cancer or pancreatic ductal adenocarcinoma;

pancreatectomy; robotic or robot-assisted surgery; open surgery; surgical and

oncological outcomes.

Proposed search string:

(

("Pancreatic Neoplasms"[Mesh] OR "pancreatic cancer"[tiab] OR "pancreatic ductal

adenocarcinoma"[tiab] OR PDAC[tiab])

AND

(

"Pancreatectomy"[Mesh] OR pancreatectomy[tiab] OR pancreaticoduodenectomy[tiab] OR

Whipple[tiab] OR "distal pancreatectomy"[tiab] OR "total pancreatectomy"[tiab])

AND

(

"Robotic Surgical Procedures"[Mesh] OR robotic[tiab] OR "robot-assisted"[tiab] OR "robot

assisted"[tiab] OR "da Vinci"[tiab])

AND

(

open[tiab] OR laparotomy[tiab] OR conventional[tiab])

AND

"surgical outcomes"[tiab] OR "oncologic outcomes"[tiab] OR "postoperative complications"[tiab] OR

(

morbidity[tiab] OR mortality[tiab] OR survival[tiab] OR "R0"[tiab] OR margin*[tiab] OR "lymph

node"[tiab] OR "lymph nodes"[tiab]))

Suggested filters: Humans and Adult: 19+ years, when the platform allows it. Do not apply a

language filter in the initial search.

Items to be recorded in the search log: exact execution date, number of results obtained,

filters applied, databases searched, reference manager used, and number of duplicates

removed.

Annex 2. Minimum data-extraction matrix

The following minimum matrix is proposed to standardize extraction by

independent reviewers and to ensure that all included studies are assessed with

7

01

Ayala-Velasco et al. (2026)

homogeneous criteria. Discrepancies should be resolved by consensus or by a

third reviewer.

Minimum field

Study identification

Data to be extracted

Record ID, first author, year of publication, and DOI.

Suggested format

Free text /

alphanumeric code.

Country and setting

Study design

Country, number of centers, type of institution, and

surgical volume when available.

Clinical trial, prospective or retrospective cohort, PSM, Predefined category.

administrative database, comparative prospective

study, or other design.

Free text.

Data source

Population

Medical record, national database, multicenter registry, Free text.

clinical trial, or institutional repository.

Adult patients with pancreatic cancer or pancreatic

ductal adenocarcinoma; diagnostic criteria and clinical

stage.

Total number and

clinical description.

Sample size

Intervention

Total number of participants and number per surgical

group.

Robotic or robot-assisted pancreatectomy; platform

used, if reported.

Total n; intervention

n; comparator n.

Free text.

Comparator

Open, laparoscopic, or minimally invasive

pancreatectomy, according to the study.

Distal pancreatectomy, pancreaticoduodenectomy,

total pancreatectomy, or another procedure.

Category and

description.

Predefined category.

Type of resection

Baseline

Age, sex, BMI, comorbidities, ASA score, tumor stage, Mean/median,

characteristics

neoadjuvant therapy, and between-group balance

variables.

proportions, or text.

Surgical outcomes

Operative time, blood loss, transfusion, conversion,

pancreatic fistula, major complications, reintervention,

mortality, and hospital stay.

Continuous or

dichotomous

measures.

Oncological outcomes R0 resection, positive margin, nodal yield, recurrence,

overall survival, and disease-free survival.

OR, HR, mean

difference,

proportions, or text.

Months; percentage;

text.

Follow-up

Follow-up duration, loss to follow-up, and timing of

recurrence or survival assessment.

Effect measures

Statistical adjustment

Measure reported by the study and its confidence

interval or p-value.

Propensity score matching, multivariable models,

weighting, stratification, or other confounding-control

methods.

OR, RR, HR, MD,

95% CI, and p.

Yes/no and

description.

Risk of bias

Tool applied: RoB 2 for randomized trials and

ROBINS-I for non-randomized studies.

Low, some

concerns, moderate,

serious, or critical.

High, moderate, low,

or very low.

Direct, partially

direct, or indirect.

Brief text.

GRADE certainty

Rating considering risk of bias, inconsistency,

indirectness, imprecision, and publication bias.

Degree of relationship with the main robotic-versus-

open comparison and with the target population.

Main methodological, clinical, or statistical limitations

identified by the reviewers.

Applicability to the

PICO question

Study limitations

Notes for synthesis

Missing data, assumptions made, need to contact

authors, and notes for tables or figures.

Brief text.

7

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