Pancreatic cancer is the 12th most common malignant tumor in the world, and the seventh leading cause of death from cancer, with a 5-year survival rate of only 10% (Chang et al., 2022). In the past 25 years, the global burden of pancreatic cancer has doubled, and it is now ranking among the top 10 cancer deaths in more than 130 countries (Klein, 2021). According to the latest data of the American Cancer Association, there were about 60,430 new patients with pancreatic cancer in 2021, of which 48,220 died. It is expected that it will become the second leading cause of death from cancer in the United States within the next 20–30 years (Siegel et al., 2021). Among the European Union, pancreatic cancer is expected to surpass breast cancer and become the third leading cause of death related to cancer (Carioli et al., 2021). In China, the 5-year survival rate of pancreatic cancer has not been significantly ameliorated in the past 10 years, with a number of only 9.9%. With population growth, the growth of the aging propulation and the influence of Western lifestyles, the incidence rate of pancreatic cancer is expected to continue to rise in the next few years (Sun et al., 2020). As a digestive tract tumor with extremely poor prognosis, the main treatment for pancreatic cancer is still a multidisciplinary approach based on traditional open surgery (Neoptolemos et al., 2018; Chang et al., 2022). Pancreatoduodenectomy is the conventional surgical treatment for periampullary malignant tumors (Kawai and Yamaue, 2011). However, due to the limitations of OPD, such as the strong trauma that it causes, slow postoperative recovery, and long hospitalization time, as well as the continuously rising expectations for diagnosis and treatment methods from the patients, surgeons are constantly pursuing to make surgeries as minimally invasive as possible (Scialpi et al., 2016; Iovanna and Dusetti, 2017; Miller et al., 2020).

In recent years, surgical treatment for pancreatic cancer has gradually developed towards minimally invasive (Heestand et al., 2015). Minimally invasive surgery does not involve digestive tract anastomosis and reconstruction, with little technical difficulty and small incisions. The visual field can be magnified by 5–10 times under laparoscopy, which can enter into narrow spaces to obtain a field of vision unmatched by open surgery. The operative field is clearer, and the surgeries are more refined. Combined with advanced medical devices such as endoscopic cutter-staplers, ultrasonic knives, energy platforms, etc., it can very well achieve the dissection, dissociation, resection and anastomosis of some particular places, reduce the pain at the site of incision after surgery, contribute to the aesthetic appearance of the incision, and reduce trauma to the patients’ minds (Harrison et al., 2022). In addition, the magnified vision of laparoscopy provides more detailed anatomical opportunities for operators, and improves the safety of the surgery and the thoroughness of clearing (Pisters et al., 2001; Zhang et al., 2011; Cesaretti et al., 2017). However, the high recurrence rate after minimally invasive surgery, the high incidence of severe pancreatic fistula and the long operation time are still unsolved problems (Sciuto et al., 2014; Kuesters et al., 2018). Although the operation time of open surgery is short, the amount of blood loss during operation is large. Therefore, whether to choose open surgery or minimally invasive surgery for the treatment of pancreatic cancer is still a subject of great controversy (Zhang et al., 2011; Zhou et al., 2019). It is hoped that through this study, we can solve this controversy and provide a foundation for the selection of intervention (surgery) for the treatment of pancreatic cancer in clinic.

The study was registered with PROSPERO and followed PRISMA-P (the preferred reporting project for system review and meta-analysis scheme) guidelines.

Surgery is gradually heading towards a minimally invasive era, and the advantages of laparoscopic surgery are becoming increasingly prominent (Sammut et al., 2017). Before that, LPD has already been widely used to treat benign and low-grade malignant tumors located at the body and tail of the pancreas. Croome et al. (Croome et al., 2014) retrospectively analyzed clinical data of pancreatic cancer patients who underwent laparoscopic duodenectomy and open resection at Mayo Clinic from January 2008 to July 2013. They found that patients who underwent minimally invasive surgery recovered quickly after surgery, could receive adjuvant treatment sooner, and had their disease-free survival time after surgery extended.

Pancreatoduodenectomy involves many vessels and organs, with complex spatial structure. Laparoscopic technic can enlarge the visual field during operation, only causes little trauma, and results in fast postoperative recovery (Jiang et al., 2019). In this study, the amount of blood loss of pancreatic cancer patients during LPD was remarkably less than that of OPD [WMD = −120.82,95% CI (−169.33, −72.30), p = 0.001], but the operation time of LPD was longer than that of OPD [WMD = 56.14,95% CI (38.39,73.89), p = 0.001]. We believe that with an accumulation of operation volume, after passing through the learning curve of the challenge period of the third stage, the operation time of LPD can be significantly shortened, and will get closer to, or even less than that of OPD. Moreover, the bleeding volume of LPD is far less than that of OPD, so the bleeding rate of LPD per unit time should be lower than that of OPD. Therefore, it can be considered that LPD has obvious advantages over OPD. Nagakawa et al. (Nagakawa et al., 2021) conducted a cohort study on 42 patients (21 patients in the left superior mesenteric artery group and 21 patients in the right superior mesenteric artery group), and pointed out that jejunal vein and lower pancreaticoduodenal artery hemorrhage often occurred on the left side of the mesenteric artery. Nussbaum D et al. (Nussbaum et al., 2014) pointed out that a lesser amount of blood loss is related to lower complication rate; reducing pancreaticoduodenal bleeding during operation can reduce the incidence of serious postoperative complications. During LPD, it is easier to find important tissues such as blood vessels and nerves, due to a clearer fenestration and higher fineness, thus reducing the quantity of intraoperative blood loss. In addition, the amount of intraoperative blood loss is related to the surgical proficiency of the operator. Some studies have pointed out that the amount of intraoperative blood loss can be decreased with the increase of learning time. Overly long operation time, an increase of blood loss during operation, and occurrence of postoperative complications will all prolong the patient’s hospitalization time (Yeo et al., 1993). Therefore, the requirements for doctors’ surgical skills are also very high. The amount of time it takes to operate is closely related to the learning curve. Some scholars have divided the learning curve of LPD into three periods: 1–11 cases is considered as the initial learning period, 12–38 cases the period of technical competency, and 39–57 cases the challenge period (Godhi et al., 2017). At the initial stage, the operation time of LPD can be long. First, because the degree of freedom and agility that endoscopic surgery allows is not as good as that of laparotomy, and second, because of the complexity and difficulty of LPD itself. For LPD beginners, when dealing with the operation difficulties, such as separation and resection of the pancreatic uncinate process, clearing of deep abdominal lymph nodes, reconstruction of digestive tract (especially pancreaticoduodenal anastomosis), it will inevitably consume a lot of the surgeon’s time (Gerstenhaber et al., 2013; Meng et al., 2022), which further explains the results we obtained this time. For long-term outcomes, our study obtained: 1-year OS [RR = 1.02, 95% CI (0.97, 1.08), p = 0.417] and 3-year OS [RR = 1.10,95% CI (0.75, 1.62), p = 0.614], for which no significant difference was observed. It may be that the number of included studies was small, and the included articles did not fully and clearly record the factors that may affect the prognosis of patients, such as the learning curve of the surgeon, the degree of tumor differentiation after surgery, the tumor stage, or the integrity of clinical data (such as whether or not the patient received adjuvant therapy). In short, even if it is impossible to assume that patients of the LDP group had a longer survival time, the current studies show that LDP has no weaker oncological outcome than ODP regarding the treatment of pancreatic cancer.

This study still contains some limitations. First of all, the included articles did not include retrospective studies, and the sample size of some studies was small, with inevitable presence of selection bias, which lead to the lower evidence quality of this research. Second, most studies were single center studies, leading to high heterogeneity between studies. The number of cases included in most studies was small, therefore it was impossible to analyze the incidence of various types of postoperative complications in detail. Third, the follow-up time after surgery was inconsistent, which may be the source of potential heterogeneity of the study.

In summary, LPD involves less blood loss and longer operation time when compared with OPD, therefore the bleeding rate per unit time of LPD is less than that of OPD. LPD has obvious advantages. With the increase of clinical application of LPD, the usage of LPD in patients with pancreatic cancer has a good prospect. Due to the limitations of this paper, in future studies, more attention should be paid to high-quality, multi-center, randomized controlled studies.