What role does hand-assistance have in minimally invasive pancreatic surgery?
MINIMALLY INVASIVE SURGERY: RATIONALE, ADVANTAGES AND LIMITATIONS
Surgery poses an important stress on the patient from both physical and psychological points of view per se. It has become clearer with time that, regardless of the type of surgical operation, a smaller surgical incision could reduce the operation-induced stress. With advancements in technology, great efforts have been made in trying to reduce this burden on the patient, leading to the development of minimally invasive surgery (MIS)[1,2]. MIS has gained increasing support since its introduction and has undergone continuous improvements and evolutions to the point of becoming, nowadays, the standard of care for many surgical procedures such as cholecystectomy, adrenalectomy, splenectomy, and fundoplication. MIS encompasses several different approaches which have in common the aim of decreasing the impact of the surgical operation on the patient. The first approach to be developed and widely accepted in clinical practice was laparoscopy. Among the well-established advantages of laparoscopic surgery, we have decreased pain, shorter length of stay, faster postoperative recovery, and a better visualization of secluded anatomical spaces which would otherwise require a large incision to be correctly exposed[3]. All of this comes at the price of decreased dexterity, diminished tactile feedback, and inherent limitations posed by restricted degrees of freedom of laparoscopic instrumentation, which may result in a longer operative time compared to the open approach for complex surgical procedures[4]. In recent years, an alternative to the laparoscopic technique has been proposed with the introduction of robotic platforms in surgery. Potential advantages of robotic surgery are filtration of tremors, better dexterity, higher degrees of freedom with the EndoWrist system, and better operative field visualization with 3D imaging. Nonetheless these advantages have to be balanced with drawbacks such as lack of haptics and high cost in terms of both initial investment in purchasing the robotic platform and single operation cost.
MIS IN THE PANCREATIC SURGERY FIELD: A STEEP PATH
Despite all the hype around these new technologies, the implementation and diffusion of MIS have been hampered by the large amount of time and dedication necessary to master the techniques to have results comparable to the open approach. The concept of learning curve became particularly popular with the advent of minimally invasive surgery, when surgeons needed to completely rethink their abilities and adapt them to new techniques and technologies. It has also been postulated that the learning curve appears to be longer in MIS relative to open surgery, and that the curve becomes steeper and steeper with the increasing complexity of surgical procedures[5]. For complex major abdominal surgeries, a great number of procedures is required to master the technique, and there may be dangerously high morbidity and mortality rates at the beginning of the learning curve. This has been particularly the case of pancreatic surgery.
Despite the appeal of MIS and its widespread adoption in several fields of surgery, the attitude of pancreatic surgeons has been initially tepid. On the one hand, there was the conceptual problem of whether in complex and demanding surgical operations such as pancreatic resections the size of the incision can truly be considered the main contributor to surgical trauma. On the other hand, some peculiar aspects of pancreatic surgery have initially hampered the widespread diffusion of the minimally invasive approach in this field: the peculiar retroperitoneal location of the pancreas, its delicate texture and proximity to major vessels, the complexity of the dissection, the concerns regarding oncological safety in the case of malignancy, the difficulty of the anastomotic components, and the still relatively high morbidity and mortality that characterize pancreatic resections[6-10]. Another more practical matter is the relative rarity of pancreatic diseases and the complexity of most cases, which make them not suitable to be approached minimally invasively by surgeons at the beginning of their learning curve; the result is an even longer time to reach proficiency and an acceptable morbidity and mortality rate[11].
Reports of the initial experience with totally laparoscopic pancreatic surgery showed no apparent advantage for pancreaticoduodenectomy, with no improvement in postoperative outcomes and increased morbidity. Conversely, the results are promising for distal pancreatectomy, since it was associated with acceptable operative time and reduced morbidity and length of stay (LOS)[12].
HAND-ASSISTED LAPAROSCOPIC SURGERY
Rationale and limitations
To overcome the difficulties in adaptation of complex procedures from an open approach, some hybrid techniques have been developed for laparoscopy.
One of the proposed approaches is hand-assisted laparoscopic surgery (HALS): a mini-laparotomy is planned through which the surgeon can insert his or her hand covered by a glove or a hand port that prevents the loss of the pneumoperitoneum. This allows for the surgical operation to be performed via laparoscopy but with the help of an intra-abdominal hand. At the beginning, this technique was greeted with skepticism because of the need to perform a laparotomic incision, which is in direct contrast with the principle of minimal invasivity and because of the lack of adequate instruments able to maintain the pneumoperitoneum with an intra-abdominally inserted hand[13]. However, with the development of appropriate instruments, HALS found its niche in enabling the surgeon to start approaching major abdominal operations in laparoscopy, with as safety net the familiarity and the expertise of having a hand directly in contact with the structures. Clear pros of this approach are restoration of the tactile feedback and better manipulation of tissues, such as better organ retraction, finger blunt dissection, exposure and control of possible unexpected intraoperative bleeding and complications[14,15], and a shorter operative time than laparoscopy[16], while maintaining some of the advantages of MIS over the open approach, notably a lower estimated blood loss and a shorter LOS. Among the cons, there is clearly the additional surgical trauma posed by the mini-laparotomy, although this problem may be partially mitigated by using this technique in operations which would already require an incision to retrieve the resected specimen. Moreover, despite the handiness of having a direct access to the abdominal cavity, the presence of the hand may reduce the space and range of movements of laparoscopic instrumentation and impair vision[13].
Fields of use
After its introduction, this technique was initially adopted in several different fields of surgery, in which a pure laparoscopic approach was still striving to be undertaken. In esophagogastric surgery, HALS was applied to both trans-hiatal esophagectomy and total and partial gastrectomy with good results in terms of postoperative and oncological outcomes[17-19]. A trial was also made in bariatric surgery, but no advantages were found over the open approach for gastric bypass in terms of incidence of incisional hernia and reduction of LOS despite an increased cost[20]. One of the areas in which HALS has had greater success is colorectal, surgery in which an incision is needed anyway, no matter the approach, to extract the specimen and possibly perform the anastomosis. HALS has been used for partial or total colectomy, anterior rectum resection, and abdominoperineal resection, and it maintains the advantages of laparoscopy in terms of bowel movements, refeeding, and hospital stay[21-24]. Another application of HALS was in the living-donor nephrectomy, where it showed a shorter warm ischemic time than pure laparoscopy, while offering a smaller incision and faster recovery than the open approach[25-28]. From initial reports, HALS appeared to facilitate the laparoscopic approach, increasing the level of subjective safety and thus shortening the learning curve.
HALS in the pancreatic surgery field
In pancreatic surgery, preliminary data were presented by Cuschieri[29] and Gagner and Gentileschi[30], in the early era of pancreatic laparoscopy, presenting the advantages of the hand-assisted technique over the totally laparoscopic approach for such major procedures in terms of safety, exposure, and oncological appropriateness. Furthermore, HALS can provide particular advantages in the case of malignancy, allowing for palpation of the tumor and manual staging, and in the case of voluminous cystic lesions, which can be more effectively removed en-bloc[31-35].
The hand-assisted pancreatic resections were performed with the insertion of trocars along with a subcostal mini-laparotomy, through which the non-dominant hand was inserted to provide traction and direct palpation, while the demolition and reconstruction phase were both accomplished via laparoscopic instrumentation by the dominant hand. In the case of Pancreaticoduodenectomy (PD), all three anastomosis were performed intracorporeally[30], which is also because mini-laparotomy is usually located in a position not favorable to be exploited for an open pancreatic anastomosis[36].
The HALS approach was mostly used to perform Distal Pancreatectomy (DP) because it is a relatively easier procedure without need for complex anastomosis and therefore a greater effort has been put in trying to make this procedure as less invasive as possible. Initial experience with totally laparoscopic DP has been encouraging, stating a marked reduction of LOS, but, at the same time, relevant limitations were identified, such as a long operative time and a high conversion rate[37,38]. At the beginning, trying to transition from a purely open approach to a totally minimally-invasive procedure, HALS appeared to be a good compromise, and several reports have been published stating its advantages[39,40]. Postlewait et al.[41] reported a lower intraoperative blood loss and shorter hospital stay than open surgery and comparable perioperative and oncological outcomes. Gamboa et al.[16] showed similar results and additionally reported a shorter operative time than totally minimally invasive approach, a similar LOS, and a lower conversion rate, even though patients undergoing hand-assisted distal pancreatectomy (HADP) had more comorbidities and a higher number of previous abdominal operations. Kneuertz et al.[42] reported the outcomes of laparoscopic DP (LDP) at their institution over an 11-year period; a reduced use of hand-assistance was observed with growing experience and a reduced LOS in TLS relative to HALS. A similar trend in reduction of HALS use over time was reported by Jayaraman et al.[43] and Nakamura et al.[44]. A relevant piece of literature includes HADP in the laparoscopic cases, and it is therefore difficult to extrapolate data on specific HADP outcomes[45-52]. The current available literature on the topic is summarized in Table 1; articles where the surgical technique is not specified were excluded. Placement of trocars and hand-port is shown in Figure 1.
Figure 1. Trocars and hand-port placement in hand-assisted laparoscopic distal pancreatectomy. The placement of trocars widely changed among different reports. Proposed placement of trocars: (A) hand-port; and (B) ports for trocars placement.
Hand-assisted laparoscopic distal pancreatectomy
| Period of enrollment | Surgical operation | Included approaches | N of HALS pancreatic procedures | HALS vs. open | HALS vs. TLS/robotic | |
| Cuschieri[29], 2000 | - | DP, TP, minor pancreatic resections, liver resections, | HALS | 2 | - | - |
| Misawa et al.[53], 2006 | 2004-2005 | DP | HALS, open | 8 | Reduced IBL, LOS Similar OT | - |
| D’Angelica et al.[39], 2006 | 2002-2004 | DP | HALS | 17 | - | - |
| Pierce et al.[54], 2007 | 2000-2006 | DP, enucleation | HALS*, TLS | 3 | - | - |
| Teh et al.[55], 2007 | 2002-2005 | DP | HALS*, TLS, open | 8 | - | - |
| Tang et al.[56], 2007 | 1999-2006 | DP | HALS*, TLS, open° | 2 | - | - |
| Nakamura et al.[44], 2008 | 2000-2007 | DP | HALS*, TLS, open | 5 | - | - |
| Laxa et al.[57], 2008 | 2002-2007 | DP | HALS, TLS | 7 | - | - |
| Vijan et al.[58], 2010 | 2004-2009 | DP | HALS*, TLS, open | 2 | - | - |
| Jayaraman et al.[43], 2010 | 2003-2009 | DP | HALS*, TLS, open | 38 | - | - |
| Gumbs et al.[59], 2012 | - | DP | HALS*, TLS | 4 | - | - |
| Kneuertz et al.[42], 2012 | 2000-2011 | DP | HALS, TLS | 62 | - | Increased LOS |
| Rostas et al.[60], 2012 | 2008-2011 | DP | HALS | 34 | - | - |
| Rutz et al.[61], 2014 | 2009-2013 | DP | HALS, TLS, open | 21 | - | Increased IBL, tumor size Similar LOS, morbidity |
| Postlewait et al.[41], 2018 | 2000-2014 | DP | HALS, TLS, robotic, open | 46 | Reduced IBL, LOS Similar specimen length, OT, and LN yield | Similar IBL, LOS |
| Gamboa et al.[16], 2020 | 2010-2018 | DP | HALS, TLS, robotic, open | 109 | Reduced IBL, LOS Similar OT, morbidity, LN yield, R0 rate | - |
Some reports have postulated a non-inferiority of the hand-assisted approach for PD relative to open, but its usefulness has been questioned[29,30,62-64]. In PD, the advantage of hand assistance does not appear to be striking. This is probably ascribable to the fact that the complex reconstruction phase, in HAPD, is performed intracorporeally, and, if a surgeon has enough laparoscopic skills to perform the reconstructive part, he conceptually should not need the help of the hand in the demolition phase[36]. Accordingly, recent literature reports a very limited adoption (0.6%) of the hand-assisted approach for PD[36]. Some hybrid approaches have been proposed, with the demolition phase performed with a hand-assisted approach and the reconstruction phase with an open approach via a mini-laparotomy[65].
LAPAROSCOPIC-ASSISTED SURGERY
A similar but somewhat different hybrid approach that appeared to be more suitable for PD is laparoscopic-assisted surgery (LAS). In LAS, the preparation and part of the demolition phase of the surgical operation is managed via laparoscopy, while the reconstruction part is performed out of the body via a small laparotomic incision[66]. With this approach, we are able to take advantage of the improved vision of secluded spaces given by the laparoscopy, sparing a large incision to the patient and granting a faster postoperative recovery, while assuring an adequate anastomosis technique and hemostasis through a small incision that can also be used for the retrieval of the resected specimen[67,68]. Several authors, in the initial phase of approaching minimally invasive PD, used a laparoscopic-assisted PD (LAPD) approach and reported their case series, proposing the feasibility of LAPD[69-74]. LAPD showed non-inferior results to open surgery in terms of perioperative and oncological outcomes (comparable number of harvested lymph nodes and higher R0 rates)[75]. Similar results were also reported by Tan et al.[76] and Mendoza et al.[77], who showed no differences in oncological and perioperative outcomes between open PD and LAPD. Tian et al.[68] reported a lower estimated blood loss and shorter time to first flatus and Wang et al.[67] described again a lower intraoperative blood loss and a shorter LOS. Additionally, a lower rate of anastomosis related complications has been reported compared to totally laparoscopic PD performed by experienced pancreatic surgeons at the beginning of their learning curve[78]. Similarly promising results were reported by Deichmann et al.[79]. No differences in intraoperative characteristics and postoperative outcomes were found between LAPD and robotic-assisted PD by Piedimonte et al.[80]. Patel et al.[81] reported a shorter LOS and lower severe morbidity rate and reoperation rate in LAPD compared to TLS, although a progressive shift from LAPD to TLS was observed over time. Somewhat similar results were published by Wang et al.[82], reporting an increased operative time and blood loss in LAPD relative to TLS but similar LOS, morbidity rate, and postoperative pancreatic fistula (POPF) rate, with LAPD adopted by more inexperienced surgeons. In addition, Goh et al.[83] reported a more frequent adoption of the hybrid technique during their early experience to allow for a safer transition to totally MIS. van Hilst et al.[84] compared postoperative outcomes in LAPD and TLS without finding any significant difference; similar results were reported by
Figure 2. Trocars and mini-laparotomy placement in laparoscopic-assisted pancreaticoduodenectomy. The placement of trocars widely changed among different reports. Proposed placement of trocars: (A) mini-laparotomy; and (B) ports for trocars placement.
Laparoscopic-assisted pancreaticoduodenectomy
| Period of enrollment | Surgical operation | Included approaches | N of LAS pancreatic procedures | LAS vs. open | LAS vs. TLS/robotic | |
| Staudacher et al.[72], 2005 | 2003-2004 | PD | LAS | 4 | - | - |
| Dulucq et al.[85], 2006 | 1999-2005 | PD | LAS, TLS | 9 | - | Similar IBL, OT, LOS |
| Pugliese et al.[91], 2008 | 2002-2006 | PD | LAS*, TLS | 7 | - | - |
| Cho et al.[70], 2009 | 2007-2008 | PD | LAS | 15 | - | - |
| Machado et al.[92], 2013 | - | PD | LAS*, TLS | 2 | - | - |
| Kim et al.[87], 2013 | 2007-2011 | PD | LAS*, TLS | 10 | - | - |
| Lee et al.[73], 2013 | 2009-2012 | PD | LAS | 42 | - | - |
| Langan et al.[89], 2014 | 2010-2013 | PD | LAS, open | 27 | Reduced LOS Better QoL Similar OT, morbidity rate | - |
| Wang et al.[67], 2014 | 2009-2013 | PD | LAS, open | 13 | Decreased blood loss, LOS Similar complication and mortality rate | - |
| Wellner et al.[90], 2014 | 1996-2013 | PD | LAS, open | 40 | Decreased need for blood transfusions Similar complication and mortality rate | - |
| Speicher et al.[86], 2014 | 2010-2013 | PD | LAS, TLS, open | 31 | Increased IBL, POPF grade C rate Similar R0 rate | Increased IBL, POPF grade C rate Similar R0 rate |
| Liang et al.[93], 2015 | 2011-2013 | PD | LAS*, TLS, open | 13 | - | - |
| Piedimonte et al.[80], 2015 | 2010-2014 | PD | LAS, RA | 14 | - | Similar OT, IBL, morbidity rate |
| Wang et al.[54], 2015 | 2010-2013 | PD | LAS, TLS | 6 | - | Similar OT, IBL, morbidity |
| Mendoza et al.[77], 2015 | 2014 | PD | LAS, open | 18 | Reduced LOS Increased OT Similar IBL, LN yield, R0 rate, morbidity rate, POPF rate | - |
| Liu et al.[71], 2015 | 2011-2012 | PD | LAS | 21 | - | - |
| Lu et al.[88], 2016 | 2012-2015 | PD | LAS*,TLS | 9 | - | - |
| Patel et al.[81], 2017 | 2006-2016 | PD | LAS, TLS | 17 | - | Reduced LOS, length of ICU stay, severe morbidity, reoperation rate |
| Kantor et al.[94], 2018 | 2014-2015 | PD | LAS*, TLS, robotic, open | 304 | - | - |
| Nassour et al.[95], 2018 | 2014-2015 | PD | LAS*, TLS, robotic, open | 54 | - | - |
| Deichmann et al.[79], 2018 | 2000-2015 | PD | LAS, open | 60 | Decreased OT, LOS, need for blood transfusions, CR-POPF rate | - |
| Kuesters et al.[75], 2018 | 2010-2016 | PD | LAS, open | 62 | Increased OT, R0 rate Comparable lymph node yield, morbidity and mortality rate Shorter LOS | - |
| Tan et al.[76], 2019 | 2014-2016 | PD | LAS, open | 20 | Increased OT Similar morbidity rate, LN yield, R0 rate Reduced time to deambulation | - |
| Goh et al.[83], 2019 | 2014-2017 | PD, TP | LAS*, TLS, robotic | 18 | - | - |
| van Hilst et al.[84], 2019 | 2014-2018 | PD | LAS, TLS | 56 | - | Increased conversion rate Similar IBL, OT, LOS, POPF rate, severe morbidity rate |
| Pham et al.[74], 2020 | 2014-2019 | PD | LAS | 18 | - | - |
| Tian et al.[68], 2020 | 2013-2018 | PD | LAS, open | 36 | Decreased blood loss Increased OT Similar CR-POPF rate, need for blood transfusions, LOS | - |
| Nieuwenhuijs et al.[78], 2020 | 2016-2017 | PD | LAS, open, TLS | 10 | Similar CR-POPF | - |
| Klompmaker et al.[96], 2020 | 2012-2017 | PD | LAS*, RA, TLS, open | 130 | - | - |
| Wang et al.[82], 2020 | 2016-2018 | PD | LAS, TLS | 48 | - | Increased OT, IBL Similar LOS, morbidity rate, POPF rate |
| Al-Sadairi et al.[69], 2021 | 2019 | PD | LAS | 21 | - | - |
MIS IN THE PANCREATIC SURGERY FIELD: WHERE ARE WE NOW?
Distal pancreatectomy
It is worth noting that, despite the initial setback, MIS has been greatly implemented in the pancreatic surgery field in recent years. Several observational studies, reviews, and metanalysis reported on the safety of minimally invasive distal pancreatectomy (MIDP) and proposed its advantages[98-106]. A multicentric randomized controlled clinical trial comparing MIDP to open distal pancreatectomy demonstrated, despite a similar major complication rate, a reduced rate of delayed gastric emptying, a reduced intraoperative blood loss, a reduced time to functional recovery, and a better quality of life[107]. In light of this evidence, MIDP has become the standard of care for benign and low malignant tumors[108]. Regarding the use of MIDP for the treatment of pancreatic ductal adenocarcinoma, available data suggest the oncological appropriateness of the procedure, but high-level evidence is still lacking. Oncological outcomes were comparable in terms of resection margins, disease free survival, and overall survival, while the number of harvested lymph nodes was found to be lower in one metanalysis and comparable in a second one[101,109,110]. The DIPLOMA trial[111] showed a higher R0 resection rate for MIDP, a less frequent Gerota’s fascia resection, a lower number of harvested lymph nodes, and a comparable median survival. Randomized clinical trials are ongoing, trying to give a definitive answer. Regarding the choice of the type of MIS technique, several observational studies have been published comparing the robotic versus laparoscopic approach. Theoretically, the robotic platform should provide advantages in terms of improved dexterity and vision, allowing for completion of more complex procedures, but whether this translates into better outcomes and cost-effectiveness in clinical practice is still controversial[112]. Reported outcomes in the literature are heterogenous: recent metanalyses showed a higher rate of splenic vessel preservation and a lower conversion rate, but higher cost in Robotic DP compared to LDP[113,114]. Another metanalysis reported a shorter LOS and an increase of spleen preservation rate at the expense of increased cost[115]. Oncological and postoperative outcomes, such as POPF rate and overall morbidity, were comparable. Other studies showed no major differences in perioperative outcomes[116-118]. Therefore, the Miami Guidelines conclude that both laparoscopic and robotic DP are considered valuable and equivalent options, and the choice between the two depends on the preference of the surgeon and his familiarity with the technique[108].
Pancreaticoduodenectomy
Pancreaticoduodenectomy is still performed in the majority of centers with an open approach due to its technical difficulty and the complex reconstructive phase. Available data on safety and feasibility of MIPD are conflicting. Reports from low-volume centers showed an increased morbidity and mortality after MIPD[119,120], while experience in high-volume centers demonstrated a similar rate of mortality and morbidity compared to OPD. Moreover, in high-volume centers, LPD showed a lower rate of DGE, decreased blood loss, and a shorter hospital stay but a longer operative time[36,121,122]. Three randomized clinical trials have been published with mixed results. Palanivelu et al.[123] showed similar oncological and perioperative outcomes in OPD and LPD. Conversely, the LEOPARD-2 trial was interrupted early because of safety concerns due to a disproportionally high number of deaths in the LPD arm[124], while the PADULAP trial reported a lower major complication rate and a shorter LOS and similar oncological outcomes[125]. No major differences in outcomes have been reported between LPD and RPD[126,127]. In view of existing evidence, the Miami Guidelines concluded that insufficient data exist to recommend MIPD over OPD. MIPD appears to be safe and feasible but only if performed by surgeons who have completed the learning curve and if set in high-volume centers experienced in both pancreatic surgery and MIS.
HALS: DOES IT STILL HAVE A ROLE IN PANCREATIC SURGERY PRACTICE TODAY?
Analysis of trends in the use of MIS in pancreatic surgery showed how, with time, we had a steep increase of MIDP, and the increase in number was paralleled by increasing complexity of procedures and a decrease in conversion rate and operative time[42]. Moreover, the proportion of procedures performed with hand assistance decreased with time as surgeons became more skilled in MIS. It is worth noting that a recent analysis showed that MIDP is only used in one third of eligible patients[128]. Therefore, on the one hand, HADP plays a very marginal role in high-volume centers, where surgeons have finished their learning curve, while, on the other hand, there are still centers in the process of implementation of MIS where HADP may play a fundamental role as a bridge to totally MIDP, easing the transition and shortening the learning curve. Moreover, HADP, with its shorter operative time, may be preferred in patients with multiple cardiological, pulmonary, and renal comorbidities who would not tolerate well the effects of prolonged anesthesia and pneumoperitoneum[16]. Furthermore, HADP may be used as an intermediary step in conversion from MIDP to open in complex cases where manual assistance or tactile feedback is required or in the case of intraoperative complications because it appears that converted hand-assisted cases have a lower estimated blood loss and a shorter LOS than open[16,30].
The role of MIS in PD is still not defined; MIPD can be performed in high-volume centers by experienced surgeons with acceptable outcomes, but the results are difficult to be generalized. In the process of the implementation of MIPD, LAPD may play a role as a bridge to totally laparoscopic PD allowing for a safer transition[129,130].
In conclusion, the choice of the right approach needs to be tailored to the patient with a focus on his or her safety and to the surgeon keeping in mind his or her limits and expertise.
DECLARATIONS
Authors’ contributionConception, design, drafting and revision of the manuscript: Donisi G, Zerbi A
Availability of data and materialsNot applicable.
Financial support and sponsorshipNone.
Conflict of interestBoth authors declared that there are no conflicts of interest.
Ethical approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Copyright© The Author(s) 2021.
REFERENCES
2. Antoniou SA, Antoniou GA, Antoniou AI, Granderath FA. Past, present, and future of minimally invasive abdominal surgery. JSLS 2015;19:e2015.
5. Subramonian K, Muir G. The “learning curve” in surgery: what is it, how do we measure it and can we influence it? BJU Int 2004;93:1173-4.
6. Zhu R, Cao Z, Qiu J, Zhang T. Minimally invasive pancreatic surgery: an upward spiral. Laparoscopic, Endoscopic and Robotic Surgery 2020;3:29-33.
7. Esposito A, Balduzzi A, De Pastena M, et al. Minimally invasive surgery for pancreatic cancer. Expert Rev Anticancer Ther 2019;19:947-58.
8. Bausch D, Keck T. Minimally invasive surgery of pancreatic cancer: feasibility and rationale. Visc Med 2018;34:440-3.
9. Sahakyan MA, Labori KJ, Primavesi F, Søreide K, Stättner S, Edwin B. Minimally invasive pancreatic surgery - where are we going? Eur Surg 2019;51:98-104.
10. Nappo G, Perinel J, El Bechwaty M, Adham M. Minimally invasive pancreatic resection: is it really the future? Dig Surg 2016;33:284-9.
11. Underwood PW, Gerber MH, Hughes SJ. Pitfalls of minimally invasive pancreatoduodenectomy. Ann Pancreat Cancer 2019;2:10.21037/apc.2018.12.02.
12. Gagner M, Pomp A. Laparoscopic pancreatic resection: Is it worthwhile? J Gastrointest Surg 1997;1:20-5; discussion 25.
13. Targarona EM, Gracia E, Rodriguez M, et al. Hand-assisted laparoscopic surgery. Arch Surg 2003;138:133-41; discussion 141.
15. Kavic MS. Hand-assisted laparoscopic surgery (HALS): a bridge to complex laparoscopic procedures. JSLS 2005;9:123-4.
16. Gamboa AC, Aveson VG, Zaidi MY, et al. Lending a hand for laparoscopic distal pancreatectomy: the optimal approach? HPB (Oxford) 2020;22:690-701.
17. animura S, Higashino M, Fukunaga Y, Osugi H. Hand-assisted laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer. Surg Laparosc Endosc Percutan Tech 2001;11:155-60.
18. Okushiba S, Ohno K, Itoh K, et al. Hand-assisted endoscopic esophagectomy for esophageal cancer. Surg Today 2003;33:158-61.
19. Fujiwara H, Shiozaki A, Konishi H, et al. Hand-assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection. Dis Esophagus 2016;29:131-8.
20. DeMaria EJ, Schweitzer MA, Kellum JM, Meador J, Wolfe L, Sugerman HJ. Hand-assisted laparoscopic gastric bypass does not improve outcome and increases costs when compared to open gastric bypass for the surgical treatment of obesity. Surg Endosc 2002;16:1452-5.
21. Gahagan JV, Garrett KA. Hand-assisted laparoscopic colon resection: review of literature and technique. Ann Laparosc Endosc Surg 2019;4:4-4.
22. Ichihara T, Nagahata Y, Nomura H, et al. Laparoscopic lower anterior resection is equivalent to laparotomy for lower rectal cancer at the distal line of resection. Am J Surg 2000;179:97-8.
23. Pietrabissa A, Moretto C, Carobbi A, Boggi U, Ghilli M, Mosca F. Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure. Surg Endosc 2002;16:431-5.
24. Tam MS, Kaoutzanis C, Mullard AJ, et al. A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc 2016;30:455-63.
25. Wolf JS Jr, Merion RM, Leichtman AB, et al. Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation 2001;72:284-90.
26. Pietrabissa A, Boggi U, Moretto C, Ghilli M, Mosca F. Laparoscopic and hand-assisted laparoscopic live donor nephrectomy. Semin Laparosc Surg 2001;8:161-7.
27. Stifelman MD, Hull D, Sosa RE, et al. Hand assisted laparoscopic donor nephrectomy: a comparison with the open approacH. J Urol 2001;166:444-8.
28. Stifelman MD, Sosa RE, Shichman SJ. Hand-assisted laparoscopy in urology. Rev Urol 2001;3:63-71.
29. Cuschieri A. Laparoscopic hand-assisted surgery for hepatic and pancreatic disease. Surg Endosc 2000;14:991-6.
30. Gagner M, Gentileschi P. Hand-assisted laparoscopic pancreatic resection. Semin Laparosc Surg 2001;8:114-25.
31. Tada S, Iida T, Anazawa T, et al. Successful laparoscopic distal pancreatectomy for a large solid pseudopapillary neoplasm: a case report. Asian J Endosc Surg 2017;10:317-20.
32. Shinchi H, Takao S, Noma H, Mataki Y, Iino S, Aikou T. Hand-assisted laparoscopic distal pancreatectomy with minilaparotomy for distal pancreatic cystadenoma. Surg Laparosc Endosc Percutan Tech 2001;11:139-43.
33. Doi R, Ito D, Fujimoto K, et al. Hand-assisted laparoscopic resection of serous cystadenoma of the pancreas. Surg Endosc 2003;17:2028-31.
34. Kaneko H, Takagi S, Joubara N, et al. Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. J Hepatobiliary Pancreat Surg 2004;11:397-401.
35. Klingler PJ, Hinder RA, Menke DM, Smith SL. Hand-assisted laparoscopic distal pancreatectomy for pancreatic cystadenoma. Surg Laparosc Endosc 1998;8:180-4.
36. Boggi U, Amorese G, Vistoli F, et al. Laparoscopic pancreaticoduodenectomy: a systematic literature review. Surg Endosc 2015;29:9-23.
37. Cuschieri A, Jakimowicz JJ, van Spreeuwel J. Laparoscopic distal 70% pancreatectomy and splenectomy for chronic pancreatitis. Ann Surg 1996;223:280-5.
38. Gagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery 1996;120:1051-4.
39. D'Angelica M, Are C, Jarnagin W, et al. Initial experience with hand-assisted laparoscopic distal pancreatectomy. Surg Endosc 2006;20:142-8.
40. Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: up-to-date and literature review. World J Gastroenterol 2012;18:5329-37.
41. Postlewait LM, Ethun CG, McInnis MR, et al. The hand-assisted laparoscopic approach to resection of pancreatic mucinous cystic neoplasms: an underused technique? Am Surg 2018;84:56-62.
42. Kneuertz PJ, Patel SH, Chu CK, et al. Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience. J Am Coll Surg 2012;215:167-76.
43. Jayaraman S, Gonen M, Brennan MF, et al. Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J Am Coll Surg 2010;211:503-9.
44. Nakamura Y, Uchida E, Aimoto T, Matsumoto S, Yoshida H, Tajiri T. Clinical outcome of laparoscopic distal pancreatectomy. J Hepatobiliary Pancreat Surg 2009;16:35-41.
45. Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg 2012;255:1048-59.
46. Kooby DA, Gillespie T, Bentrem D, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008;248:438-46.
47. Patterson EJ, Gagner M, Salky B, et al. Laparoscopic pancreatic resection: single-institution experience of 19 patients1 1No competing interests declared. J Am Coll Surg 2001;193:281-7.
48. Edwin B, Mala T, Mathisen Ø, et al. Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome. Surg Endosc 2004;18:407-11.
49. Lyu Y, Cheng Y, Wang B, Zhao S, Chen L. Comparison of 3 minimally invasive methods versus open distal pancreatectomy: a systematic review and network meta-analysis. Surg Laparosc Endosc Percutan Tech 2020;31:104-12.
50. Goh BKP, Lee SY, Kam JH, et al. Evolution of minimally invasive distal pancreatectomies at a single institution. J Minim Access Surg 2018;14:140-5.
51. Machado MA, Surjan RC, Goldman SM, Ardengh JC, Makdissi FF. Laparoscopic pancreatic resection. From enucleation to pancreatoduodenectomy. 11-year experience. Arq Gastroenterol 2013;50:214-8.
52. Root J, Nguyen N, Jones B, et al. Laparoscopic distal pancreatic resection. Am Surg 2005;71:744-9.
53. Misawa T, Shiba H, Usuba T, et al. Systemic inflammatory response syndrome after hand-assisted laparoscopic distal pancreatectomy. Surg Endosc 2007;21:1446-9.
54. Pierce RA, Spitler JA, Hawkins WG, et al. Outcomes analysis of laparoscopic resection of pancreatic neoplasms. Surg Endosc 2007;21:579-86.
55. Teh SH, Tseng D, Sheppard BC. Laparoscopic and open distal pancreatic resection for benign pancreatic disease. J Gastrointest Surg 2007;11:1120-5.
56. Tang CN, Tsui KK, Ha JP, Wong DC, Li MK. Laparoscopic distal pancreatectomy: a comparative study. Hepatogastroenterology 2007;54:265-71.
57. Laxa BU, Carbonell AM 2nd, Cobb WS, et al. Laparoscopic and hand-assisted distal pancreatectomy. Am Surg 2008;74:481-6; discussion 486.
58. Vijan SS, Ahmed KA, Harmsen WS, et al. Laparoscopic vs open distal pancreatectomy: a single-institution comparative study. Arch Surg 2010;145:616-21.
59. Gumbs AA, Chouillard EK. Laparoscopic distal pancreatectomy and splenectomy for malignant tumors. J Gastrointest Cancer 2012;43:83-6.
60. Rostas JW, Richards WO, Thompson LW. Improved rate of pancreatic fistula after distal pancreatectomy: parenchymal division with the use of saline-coupled radiofrequency ablation. HPB (Oxford) 2012;14:560-4.
61. Rutz DR, Squires MH, Maithel SK, et al. Cost comparison analysis of open versus laparoscopic distal pancreatectomy. HPB (Oxford) 2014;16:907-14.
62. Ammori BJ. Laparoscopic hand-assisted pancreaticoduodenectomy: initial UK experience. Surg Endosc 2004;18:717-8.
63. Wang M, Zhang H, Wu Z, Zhang Z, Peng B. Laparoscopic pancreaticoduodenectomy: single-surgeon experience. Surg Endosc 2015;29:3783-94.
64. Gumbs AA, Rodriguez Rivera AM, Milone L, Hoffman JP. Laparoscopic pancreatoduodenectomy: a review of 285 published cases. Ann Surg Oncol 2011;18:1335-41.
65. Kimura Y, Hirata K, Mukaiya M, Mizuguchi T, Koito K, Katsuramaki T. Hand-assisted laparoscopic pylorus-preserving pancreaticoduodenectomy for pancreas head disease. Am J Surg 2005;189:734-7.
66. Sánchez-Cabús S, Pittau G, Gelli M, Memeo R, Schwarz L, Sa Cunha A. Laparoscopic pancreaticoduodenectomy: hybrid surgical technique. J Am Coll Surg 2015;220:e7-11.
67. Wang Y, Bergman S, Piedimonte S, Vanounou T. Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach. Can J Surg 2014;57:263-70.
68. Tian F, Wang YZ, Hua SR, Liu QF, Guo JC. Laparoscopic assisted pancreaticoduodenectomy: an important link in the process of transition from open to total laparoscopic pancreaticoduodenectomy. BMC Surg 2020;20:89.
69. Al-Sadairi AR, Mimmo A, Rhaiem R, et al. Laparoscopic hybrid pancreaticoduodenectomy: initial single center experience. Ann Hepatobiliary Pancreat Surg 2021;25:102-11.
70. Cho A, Yamamoto H, Nagata M, et al. Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease. Am J Surg 2009;198:445-9.
71. Liu Z, Yu MC, Zhao R, et al. Laparoscopic pancreaticoduodenectomy via a reverse - “V” approach with four ports: initial experience and perioperative outcomes. World J Gastroenterol 2015;21:1588-94.
72. Staudacher C, Orsenigo E, Baccari P, Di Palo S, Crippa S. Laparoscopic assisted duodenopancreatectomy. Surg Endosc 2005;19:352-6.
73. Lee JS, Han JH, Na GH, et al. Laparoscopic pancreaticoduodenectomy assisted by mini-laparotomy. Surg Laparosc Endosc Percutan Tech 2013;23:e98-102.
74. Pham H, Nahm CB, Hollands M, et al. Hybrid laparoscopic pancreaticoduodenectomy: an Australian experience and a proposed process for implementation. ANZ J Surg 2020;90:1422-7.
75. Kuesters S, Chikhladze S, Makowiec F, et al. Oncological outcome of laparoscopically assisted pancreatoduodenectomy for ductal adenocarcinoma in a retrospective cohort study. Int J Surg 2018;55:162-6.
76. Tan JKH, Ng JJ, Yeo M, et al. Propensity score-matched analysis of early outcomes after laparoscopic-assisted versus open pancreaticoduodenectomy. ANZ J Surg 2019;89:E190-4.
77. Mendoza AS 3rd, Han HS, Yoon YS, Cho JY, Choi Y. Laparoscopy-assisted pancreaticoduodenectomy as minimally invasive surgery for periampullary tumors: a comparison of short-term clinical outcomes of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 2015;22:819-24.
78. Nieuwenhuijs VB, de Klein GW, van Duijvendijk P, Patijn GA. Lessons learned from the introduction of laparoscopic pancreaticoduodenectomy. J Laparoendosc Adv Surg Tech A 2020;30:495-500.
79. Deichmann S, Bolm LR, Honselmann KC, et al. Perioperative and long-term oncological results of minimally invasive pancreatoduodenectomy as hybrid technique - a matched pair analysis of 120 cases. Zentralbl Chir 2018;143:155-61.
80. Piedimonte S, Wang Y, Bergman S, Vanounou T. Early experience with robotic pancreatic surgery in a Canadian institution. Can J Surg 2015;58:394-401.
81. Patel B, Leung U, Lee J, Bryant R, O'Rourke N, Cavallucci D. Laparoscopic pancreaticoduodenectomy in Brisbane, Australia: an initial experience. ANZ J Surg 2018;88:E440-4.
82. Wang C, Qi R, Li H, Shi X. Comparison of perioperative and oncological outcomes of hybrid and totally laparoscopic pancreatoduodenectomy. Med Sci Monit 2020;26:e924190.
83. Goh BKP, Low TY, Kam JH, Lee SY, Chan CY. Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases. ANZ J Surg 2019;89:E137-41.
84. Hilst J, de Rooij T, van den Boezem PB, et al; Dutch Pancreatic Cancer Group. Laparoscopic pancreatoduodenectomy with open or laparoscopic reconstruction during the learning curve: a multicenter propensity score matched study. HPB (Oxford) 2019;21:857-64.
85. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic pancreaticoduodenectomy for benign and malignant diseases. Surg Endosc 2006;20:1045-50.
86. Speicher PJ, Nussbaum DP, White RR, et al. Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy. Ann Surg Oncol 2014;21:4014-9.
87. Kim SC, Song KB, Jung YS, et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pylorus-preserving pancreatoduodenectomy: improvement with surgical experience. Surg Endosc 2013;27:95-103.
88. Lu C, Jin W, Mou YP, et al. Analysis of learning curve for laparoscopic pancreaticoduodenectomy. J Vis Surg 2016;2:145.
89. Langan RC, Graham JA, Chin AB, et al. Laparoscopic-assisted versus open pancreaticoduodenectomy: early favorable physical quality-of-life measures. Surgery 2014;156:379-84.
90. Wellner UF, Küsters S, Sick O, et al. Hybrid laparoscopic versus open pylorus-preserving pancreatoduodenectomy: retrospective matched case comparison in 80 patients. Langenbecks Arch Surg 2014;399:849-56.
91. Pugliese R, Scandroglio I, Sansonna F, et al. Laparoscopic pancreaticoduodenectomy: a retrospective review of 19 cases. Surg Laparosc Endosc Percutan Tech 2008;18:13-8.
92. Machado MA, Makdissi FF, Surjan RC, Machado MC. Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction: an old trick for a new dog. J Laparoendosc Adv Surg Tech A 2013;23:146-9.
93. Liang S, Jayaraman S. Getting started with minimally invasive pancreaticoduodenectomy: is it worth it? J Laparoendosc Adv Surg Tech A 2015;25:712-9.
94. Kantor O, Pitt HA, Talamonti MS, et al. Minimally invasive pancreatoduodenectomy: is the incidence of clinically relevant postoperative pancreatic fistula comparable to that after open pancreatoduodenectomy? Surgery 2018;163:587-93.
95. Nassour I, Wang SC, Christie A, et al. Minimally invasive versus open pancreaticoduodenectomy: a propensity-matched study from a national cohort of patients. Ann Surg 2018;268:151-7.
96. Klompmaker S, van Hilst J, Wellner UF, et al. European consortium on Minimally Invasive Pancreatic Surgery (E-MIPS). Outcomes after minimally-invasive versus open pancreatoduodenectomy: a pan-european propensity score matched study. Ann Surg 2020;271:356-63.
97. Kuroki T, Adachi T, Okamoto T, Kanematsu T. A non-randomized comparative study of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. Hepatogastroenterology 2012;59:570-3.
98. Ohtsuka T, Nagakawa Y, Toyama H, et al. A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients. J Hepatobiliary Pancreat Sci 2020;27:47-55.
99. Jusoh AC, Ammori BJ. Laparoscopic versus open distal pancreatectomy: a systematic review of comparative studies. Surg Endosc 2012;26:904-13.
100. Mehrabi A, Hafezi M, Arvin J, et al. A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it's time to randomize. Surgery 2015;157:45-55.
101. Nakamura M, Nakashima H. Laparoscopic distal pancreatectomy and pancreatoduodenectomy: is it worthwhile? J Hepatobiliary Pancreat Sci 2013;20:421-8.
102. Nigri GR, Rosman AS, Petrucciani N, et al. Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 2011;25:1642-51.
103. Ricci C, Casadei R, Taffurelli G, et al. Laparoscopic versus open distal pancreatectomy for ductal adenocarcinoma: a systematic review and meta-analysis. J Gastrointest Surg 2015;19:770-81.
104. Pericleous S, Middleton N, McKay SC, Bowers KA, Hutchins RR. Systematic review and meta-analysis of case-matched studies comparing open and laparoscopic distal pancreatectomy: is it a safe procedure? Pancreas 2012;41:993-1000.
105. Xie K, Zhu YP, Xu XW, Chen K, Yan JF, Mou YP. Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: a meta-analysis. World J Gastroenterol 2012;18:1959-67.
106. Braga M, Pecorelli N, Ferrari D, Balzano G, Zuliani W, Castoldi R. Results of 100 consecutive laparoscopic distal pancreatectomies: postoperative outcome, cost-benefit analysis, and quality of life assessment. Surg Endosc 2015;29:1871-8.
107. Rooij T, van Hilst J, van Santvoort H, et al; Dutch pancreatic cancer group. minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg 2019;269:2-9.
108. Asbun HJ, Moekotte AL, Vissers FL, et al. International Study Group on Minimally Invasive Pancreas Surgery (I-MIPS). The miami international evidence-based guidelines on minimally invasive pancreas resection. Ann Surg 2020;271:1-14.
109. Hilst J, Korrel M, de Rooij T, et al; DIPLOMA study group. Oncologic outcomes of minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. Eur J Surg Oncol 2019;45:719-27.
110. Riviere D, Gurusamy KS, Kooby DA, et al. Laparoscopic versus open distal pancreatectomy for pancreatic cancer. Cochrane Database Syst Rev 2016;4:CD011391.
111. Hilst J, de Rooij T, Klompmaker S, et al; European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS). Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study. Ann Surg 2019;269:10-7.
112. Lefor AK. Robotic and laparoscopic surgery of the pancreas: an historical review. BMC Biomed Eng 2019;1:2.
113. Xu SB, Jia CK, Wang JR, Zhang RC, Mou YP. Do patients benefit more from robot assisted approach than conventional laparoscopic distal pancreatectomy? J Formos Med Assoc 2019;118:268-78.
114. Xourafas D, Ashley SW, Clancy TE. Comparison of perioperative outcomes between open, laparoscopic, and robotic distal pancreatectomy: an analysis of 1815 patients from the ACS-NSQIP procedure-targeted pancreatectomy database. J Gastrointest Surg 2017;21:1442-52.
115. Niu X, Yu B, Yao L, et al. Comparison of surgical outcomes of robot-assisted laparoscopic distal pancreatectomy versus laparoscopic and open resections: A systematic review and meta-analysis. Asian J Surg 2019;42:32-45.
116. Huang B, Feng L, Zhao J. Systematic review and meta-analysis of robotic versus laparoscopic distal pancreatectomy for benign and malignant pancreatic lesions. Surg Endosc 2016;30:4078-85.
117. Gavriilidis P, Lim C, Menahem B, Lahat E, Salloum C, Azoulay D. Robotic versus laparoscopic distal pancreatectomy - the first meta-analysis. HPB (Oxford) 2016;18:567-74.
118. Lyman WB, Passeri M, Sastry A, et al. Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center. Surg Endosc 2019;33:2991-3000.
119. Adam MA, Choudhury K, Dinan MA, et al. Minimally invasive versus open pancreaticoduodenectomy for cancer: practice patterns and short-term outcomes among 7061 patients. Ann Surg 2015;262:372-7.
120. Dokmak S, Ftériche FS, Aussilhou B, et al. Laparoscopic pancreaticoduodenectomy should not be routine for resection of periampullary tumors. J Am Coll Surg 2015;220:831-8.
121. Sharpe SM, Talamonti MS, Wang CE, et al. Early national experience with laparoscopic pancreaticoduodenectomy for ductal adenocarcinoma: a comparison of laparoscopic pancreaticoduodenectomy and open pancreaticoduodenectomy from the national cancer data base. J Am Coll Surg 2015;221:175-84.
122. Lai EC, Tang CN. Current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a comprehensive review. Asian J Endosc Surg 2013;6:158-64.
123. Palanivelu C, Senthilnathan P, Sabnis SC, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg 2017;104:1443-50.
124. van Hilst J, de Rooij T, Bosscha K, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol 2019;4:199-207.
125. Poves I, Burdío F, Morató O, et al. Comparison of perioperative outcomes between laparoscopic and open approach for pancreatoduodenectomy: the PADULAP randomized controlled trial. Ann Surg 2018;268:731-9.
126. Nassour I, Wang SC, Porembka MR, et al. Robotic versus laparoscopic pancreaticoduodenectomy: a NSQIP analysis. J Gastrointest Surg 2017;21:1784-92.
127. Jiang DJ, Hogg ME. Robotic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy. Laparosc Surg 2021;5:22-22.
128. Konstantinidis IT, Lewis A, Lee B, et al. Minimally invasive distal pancreatectomy: greatest benefit for the frail. Surg Endosc 2017;31:5234-40.
129. Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol 2016;13:227-38.
Cite This Article
Open Access
How to Cite
Donisi, G.; Zerbi, A. What role does hand-assistance have in minimally invasive pancreatic surgery?. Mini-invasive. Surg. 2021, 5, 38. http://dx.doi.org/10.20517/2574-1225.2021.55
Download Citation
Export Citation File:
Type of Import
Tips on Downloading Citation
Citation Manager File Format
Type of Import
Direct Import: When the Direct Import option is selected (the default state), a dialogue box will give you the option to Save or Open the downloaded citation data. Choosing Open will either launch your citation manager or give you a choice of applications with which to use the metadata. The Save option saves the file locally for later use.
Indirect Import: When the Indirect Import option is selected, the metadata is displayed and may be copied and pasted as needed.
About This Article
Special Issue
Copyright
Comments
Comments must be written in English. Spam, offensive content, impersonation, and private information will not be permitted. If any comment is reported and identified as inappropriate content by OAE staff, the comment will be removed without notice. If you have any queries or need any help, please contact us at support@oaepublish.com.