Minimally invasive pancreatic resection (MIPR). Is it time for a randomized study?

Laparoscopic approach is now performed for most of traditional open techniques, and advantages of some of laparoscopic operations have been proved by RCTs. Among several kinds of laparoscopic abdominal surgeries, minimally invasive pancreatic resection (MIPR) is growing slowly due to retroperitoneal location, spatial relationship with major vessels, and frequent occurrence of pancreatic fistula. First laparoscopic pancreatectomy, laparoscopic pancreatoduodenectomy (LPD), was performed by Prof. Gagner in 1994, and laparoscopic distal pancreatectomy (LDP) in 1996. LDP is more widely performed worldwide than LPD, and many comparative studies have been published except for RCT. Although there is no RCT, a propensity score matching (PSM) study, supposed to be equivalent to RCT, was published with a large number of patients. Benefits of LDP over open method in the PSM study includes not only less blood loss, faster recovery from operation and shorter hospital stay, but also fewer rate of pancreatic fistula and perioperative morbidities.Minimally invasive pancreatoduodenectomy (MIPD) needs to overcome complicated step, anastomosis of pancreatic stump, which is not necessary for LDP. Because of this complicated step, there are several kinds of different methods, laparoscopic, hybrid, HALS, robotic and hybrid of robotic and laparoscopic, and there are currently few evidences. Current status of MIPR will be reviewed including evidences described above.