Pancreatic anastomosis in minimally invasive pancreaticoduodenectomy: a systematic review of detailed techniques.

Minimally invasive pancreaticoduodenectomy is gaining success among surgeons also for the increasing use of robotic approach. Ideal candidates are patients with small, confined tumor and dilatated Wirsung duct which is a quite rare clinical conditions: in fact, most of minimally invasive pancreaticoduodenectomies are performed for periampullary cancer, easy to remove but with soft pancreatic remnant and tiny Wirsung duct. The result is the technical challenge of the pancreatico-enteric reconstructions. Moreover, most authors reported quite acceptable rate of clinically relevant post-operative pancreatic fistula after these complex procedures without detailed description of their reconstruction techniques. A systematic search of the literature was performed identifying relevant articles between 2012 and July 2023 about minimally invasive pancreaticoduodenectomy. The inclusion criteria were studies giving a detailed description (including iconography) of the pancreatic anastomosis during laparoscopic or robotic pancreatoduodenectomy. The aim of this review is to focus on the technical aspects of pancreatico-enteric reconstruction, considering only those studies reporting detailed description of the anastomosis with clear illustrations with the intent to allow to readers to successfully reproduce the technique. Among all reported studies, the double layer pancreaticojejunostomy with duct-to-mucosa, in association with duct stenting, is the preferred anastomosis. According with this review the double layer pancreaticojejunostomy with duct-to-mucosa is the preferred anastomosis during minimally invasive pancreaticoduodenectomy. Other RCT should be advocated to reach strong evidence for a uniformly adopted reconstruction method.