Safety and learning curve of robotic pancreatoduodenectomy with limited robotic platform access: a propensity score-matched comparison with open surgery in a high-volume center.

Background: Pancreatoduodenectomy (PD) is a major surgical procedure that is still mostly performed via open approach [open PD (OPD)] since the laparoscopic approach (LA) is limited outside specialised centers. Robot-assisted PD (RPD) appears to decrease the difficulties associated with LA. However, previously published studies are partly biased because they stem from institutions with extensive access to robotic platforms (ARPs). The present study aims to analyse the safety of RPD compared with OPD and the specific learning curve when performed with limited ARP. Methods: This prospective single-center study was conducted in a high-volume pancreatic surgery center but with limited ARP between May 2018 and October 2023. Safety (primary endpoint: 90-day mortality) was assessed using propensity score matching (2:1) to compare RPD and OPD. The learning curve was evaluated using cumulative sum (CUSUM) control chart analysis (split into three consecutive periods of 20 patients), focusing on operative time and complications. Results: A total of 354 PD were analysed, of which 60 (17%) were RPD. A matched cohort of 120 OPD was used for comparison. The conversion rate was 15% in the RPD group. The 90-day mortality rate was 5% and 8.3% for RPD and OPD, respectively (P=0.55). The RPD learning curve showed a reduction in hospital stay (19.9 Conclusions: Even with limited ARP, setting up a robotic program for PD is feasible and safe but it requires a learning curve of 40 patients. During this initial phase, careful patient selection is mandatory.