Robotic distal pancreatectomy: a comparative systematic review and meta-analysis of classic, Kimura, and Warshaw...

Distal pancreatectomy (DP) remains a technically challenging procedure associated with substantial morbidity. With the advent of robotic surgery, three primary techniques have emerged: robotic classic distal pancreatectomy (RCDP; including splenectomy), the vessel-preserving Kimura technique (KT), and the vessel-sacrificing Warshaw technique (WT). These approaches differ in splenic vessel management, leading to varying perioperative risks and long-term splenic outcomes. We performed a comprehensive meta-analysis comparing these techniques across multiple clinical endpoints. We systematically searched PubMed, Embase, and Cochrane CENTRAL from inception through December 2023, supplemented by manual citation screening. Eligible studies included randomized trials or comparative observational cohorts reporting ≥ 2 techniques with extractable data on operative time, blood loss, or spleen preservation. Data were pooled using random-effects models. Heterogeneity was assessed via I², with subgroup and sensitivity analyses conducted to explore variability. Twenty-two studies (total N ≈ 3,280), including 3 RCTs and 19 retrospective cohorts, met inclusion criteria. RCDP was associated with longer operative times compared with KT (mean difference [MD] 42.3 min, 95% CI 25.1-59.5) and WT (MD 38.7 min, 95% CI 22.4-55.0), but demonstrated reduced intraoperative blood loss versus KT (MD - 85 mL, 95% CI - 120 to - 50) and WT (MD - 78 mL, 95% CI - 110 to - 46). Spleen preservation was highest with KT (98.2%) and WT (96.5%), compared with RCDP (82.1%). No significant differences were observed in clinically relevant postoperative pancreatic fistula (POPF grade B/C), overall complications, or length of hospital stay. RCDP showed lower conversion rates (OR 0.32 vs. KT; OR 0.29 vs. WT). WT was associated with increased late complications, including gastric varices (8.3%) compared with KT (1.2%). Robotic approaches reduced splenic infarction in WT (7.6% robotic vs. 27.5% laparoscopic), and BMI > 28 kg/m², lesion size > 51 mm, and prior abdominal surgery were identified as independent predictors of conversion. RCDP offers superior hemorrhage control and lower conversion risk, but at the cost of reduced spleen preservation and longer operative time. KT and WT provide excellent spleen salvage with comparable short-term safety, though WT carries higher late splenic complication rates. Robotic platforms appear to mitigate some traditional limitations of WT, particularly splenic infarction. However, KT carries a previously underrecognized risk of splenic venous stenosis (41%), potentially leading to left-sided portal hypertension. Technique selection should be individualized based on tumor characteristics, surgical expertise, and patient-specific factors. Future randomized trials should focus on long-term splenic function and cost-effectiveness.