Standardization of single surgeon robotic pancreatoduodenectomy: lessons from 2 decades of stepwise robotic HPB...

The robotic approach has been increasingly used for complex pancreatic surgery, including Pancreatoduodenectomy (PD), yet variability in techniques limits reproducibility. This dynamic manuscript shows a standardized operative sequence for a single surgeon (without the need for a surgeon at the bedside) for robotic PD.

We retrospectively reviewed consecutive patients who underwent RPDs between January 2020 and July 2025, representing the plateau phase of a robotic program initiated in 2012. Demographic, operative, and postoperative variables were collected from a prospectively maintained database. The operative technique was standardized into defined steps for exposure, resection, and reconstruction, including preferred techniques of pancreatojejunostomy, hepaticojejunostomy, and duodenojejunostomy.

Among a total of 270 RPD, 129 procedures were done from 2020 until 2025 and represent the most mature phase of our program, with a median age of 69 years; 86% had malignancy, and 72.9% underwent pylorus-preserving procedures. Median estimated blood loss was 200 mL, transfusion rate 15%, and operative time 429 min. Conversion to open surgery occurred in 14%, predominantly for vascular resection. Median length of stay was 7 days, 90-day readmission was 31%, and mortality was 2.3%. High-grade complications (Clavien-Dindo ≥ III) occurred in 27%, with delayed gastric emptying in 10.8% and grade C pancreatic fistula in 7.8%.

A standardized, stepwise technique for a single surgeon RPD enables consistent and safe outcomes in a high-volume program. Technical reproducibility appears essential for optimal perioperative outcomes, surgical training, and broader adoption of RPD.