Non-inferiority of robotic versus open pancreatoduodenectomy - a systematic review and meta-analysis of prospective non-randomized and randomized trials

With the recent publication of the first randomized controlled trials (RCTs) comparing robotic partial pancreatoduodenectomy (RPD) versus open partial pancreaticoduodenectomy (OPD) now providing high-level evidence, this study aims to analyze the short-term outcomes of RPD versus OPD to answer the ongoing clinical debate regarding the advantages and limitations of RPD, particularly in terms of perioperative safety.

We searched Medline, Web of Science, and CENTRAL accessed last on 26th of November 2025 for prospective studies. The main outcome was 90-day mortality; secondary outcomes included complications, and short-term oncological outcomes (R0 resection rate), among others. A random-effects model was employed. Risk of bias was assessed using the Cochrane risk-of-bias-tool (RoB 2) for randomized controlled trials (RCTs), and the ROBINS-I-tool for comparative cohort trials (CCTs). The certainty of evidence was graded according to GRADE. (PROSPERO registration ID: CRD42024523577).

Out of a total of 7388 screened studies, 358 studies underwent full-text screening leading to inclusion of 7 studies (3 RCTs and 4 CCTs). No significant difference was observed between RPD and OPD for 90-day mortality [OR (95% CI) 1.07 (0.04, 29.40)], clinically relevant complications including postoperative pancreatic fistula (POPF), or reoperation rates [OR (95% CI) 1.10 (0.47, 2.59)]. Lymph node yield, R0 resection rate, operative time and length of hospital stay were also not significantly different. However, readmission rates favored OPD [OR (95% CI) 1.22 (1.15, 1.28)], while there was a lower amount of intraoperative blood loss in RPD [SMD (95% CI) -0.98 (-1.65, -0.32)].

In this systematic review and meta-analysis, mortality following RPD was comparable to OPD. RPD has demonstrated similar rates for major complications and short-term oncological outcomes and can thus be equally recommended as OPD but this recommendation is limited to experienced, high-volume centers.

This systematic review and meta-analysis was investigator-initiated and did not receive additional funding.