Pancreatic surgery remains one of the most technically demanding abdominal procedures, associated with high postoperative morbidity (1, 2). Although advances in surgical techniques and perioperative management have markedly reduced postoperative mortality in high-volume centers, the incidence of complications after distal pancreatectomy (DP) remains as high as 40%–60% (3).

Compared with open surgery, minimally invasive approaches offer several advantages, including reduced surgical trauma, less intraoperative blood loss, and faster recovery, which may translate into improved perioperative outcomes (4, 5). Since Gagner et al. first reported minimally invasive DP in 1996, laparoscopic distal pancreatectomy (LDP) has gained increasing acceptance among pancreatic surgeons (6). However, conventional laparoscopy is limited by reduced instrument dexterity, two-dimensional visualization, and a steep learning curve (7). In contrast, robotic surgery maintains the advantages of minimally invasive techniques while providing three-dimensional visualization, enhanced instrument flexibility, tremor filtration, and a shorter learning curve (6, 7). Several cohort studies have compared robotic distal pancreatectomy (RDP) and open distal pancreatectomy (ODP) in terms of surgical outcomes (8–10). However, due to potential differences in baseline characteristics between study groups, results from these observational studies remain inconsistent and inconclusive (11). There is still a lack of high-quality evidence to confirm the advantages of robotic surgery in DP. To date, no randomized controlled trials (RCTs) have directly compared the efficacy of RDP and ODP. Propensity score matching (PSM) is a robust statistical approach that minimizes confounding by balancing baseline variables between groups, thereby reducing selection bias in observational studies (11, 12). Well-designed PSM studies have been shown to provide evidence comparable to that of RCTs (12, 13). In recent years, several PSM studies (2, 6, 14) have examined RDP vs. ODP, yet their findings remain heterogeneous.

Therefore, to provide more robust and high-quality evidence regarding the role of robotic surgery in DP, we conducted a comprehensive meta-analysis including only PSM studies to compare the short-term outcomes of RDP and ODP.

Based on data from 1,526 patients across seven PSM studies, our meta-analysis demonstrated that RDP significantly reduced intraoperative blood loss, improved spleen preservation, lowered SSI rates, and shortened hospital stays compared with conventional ODP. In contrast, no significant differences were observed in 90-day mortality or morbidity. These findings provide important clinical evidence that RDP is not inferior to ODP in short-term safety and may offer additional perioperative benefits, assisting surgeons in selecting the optimal surgical approach.

In recent years, there has been increasing evidence that minimally invasive surgery, especially robotic surgery, can reduce surgical trauma and enhance postoperative recovery during major abdominal procedures such as colorectal surgery and gastrectomy (18–20). A RCT conducted by de Rooij et al. demonstrated that minimally invasive distal pancreatectomy (MIDP) promotes faster functional recovery and leads to improved quality of life compared with ODP (21). A meta-analysis by Manara et al. showed that robotic total gastrectomy significantly reduced intraoperative blood loss, time to first flatus, time to first ambulation, time to first liquid diet resumption, and hospital stay compared to open total gastrectomy (20). In addition, the study of Song et al. showed that robotic surgery could reduce the incidence of delayed gastric emptying (6). These improvements in postoperative recovery may contribute to shorter hospital stays, consistent with our finding that RDP was associated with a significantly shorter length of stay than ODP. A recent non-PSM study by Zhou et al. (9) also demonstrated that, compared with the conventional ODP group, the RDP group had less intraoperative blood loss, reduced transfusion requirements, and a shorter hospital stay. Postoperative complications are key indicators for evaluating the safety of surgical approaches, as they not only prolong hospitalization but also increase healthcare costs (22, 23). Weinberg et al. reported that patients with minor complications (Clavien–Dindo < III) experienced a median 17.1% increase in hospitalization costs, while those with major complications faced a 252% increase (23). Our study showed that the overall complication and major complication rates for RDP and ODP were comparable. The two groups were also comparable in terms of mortality. This is consistent with the results of the previous meta-analysis by Zhou et al. (7). Moreover, two RCTs have demonstrated that the postoperative complication rate of MIDP is comparable to that of ODP (21, 24). POPF remains one of the most common and clinically significant complications following DP (25). Reported incidences range from 24%–38% for all grades and 13%–17% for clinically relevant POPF (grade B and C) (25–27). The mortality of grade C POPF is as high as 30% (12). Considering the clinical value of POPF, we only analyzed the differences between the two surgical approaches in terms of clinically relevant POPF. Our study showed that the incidence of POPF in the robotic group (17.3%) was comparable to that in the open group (18.3%). SSI is the main cause of postoperative morbidity after major abdominal surgery. SSI greatly increases the financial burden and may require additional diagnostic tests and treatment (28). Several studies have suggested that robotic surgery may lower SSI risk (29, 30), likely due to smaller incisions and reduced tissue trauma (7). Our findings confirm the advantage of robotic surgery in decreasing SSI rates.

Spleen preservation is a key goal in DP for benign and low-grade malignant diseases (31, 32). However, maintaining splenic vasculature remains technically challenging during ODP (33). Robotic systems, with enhanced three-dimensional visualization, wristed instruments, and tremor reduction, facilitate these delicate dissections (7, 12). Several meta-analyses (34, 35) have shown that robotic surgery significantly improves spleen preservation compared to laparoscopic surgery. Our findings further confirm the benefits of RDP in preserving the spleen.

Complete tumor resection and adequate lymph node dissection are critical for the effective treatment of pancreatic tumors (36). Howard et al. demonstrated that R0 resection is associated with improved long-term survival (36). Furthermore, sufficient lymph node harvest is essential for accurate staging and prognosis (37). The number of lymph nodes acquired was an independent prognostic factor for patients. Wang et al. (37) reported that a minimum of 19 lymph nodes should be examined to ensure adequate staging in patients undergoing DP for pancreatic cancer. In our study, RDP and ODP were comparable in both R0 resection rates and the number of lymph nodes retrieved, consistent with the findings of Zhou et al. (7). Furthermore, a recent non-PSM study by Kamarajah et al. also demonstrated that there were no significant differences among RDP, LDP, and ODP in terms of R0 resection rates and the number of lymph nodes retrieved (38).

The high cost remains a major drawback of the robotic approach, which may be partly attributed to the additional instruments required for robotic surgery (2). Several retrospective studies (39, 40) have demonstrated that RDP is associated with significantly higher hospitalization costs compared with LDP. In contrast, RDP has been shown to reduce hospital costs relative to ODP (41, 42). With the increasing global adoption and technological maturation of robotic systems, the associated costs are expected to decline over time (39). However, because cost-effectiveness data were lacking in the included studies, further investigations are warranted to comprehensively assess the economic value of the robotic approach.

Our research has the following advantages. On the one hand, we conducted a comprehensive literature search, minimizing potential selection bias. On the other hand, we set strict inclusion criteria and included only PSM studies, enhancing the reliability of our results.

There are some limitations to this meta-analysis. First, the meta-analysis included a limited number of studies, some with small sample sizes. Second, all included studies were cohort studies, as no randomized controlled trials were available. Third, some outcomes (e.g., blood loss, length of hospital stay, operation time, number of lymph nodes harvested, and spleen preservation rate) exhibited high heterogeneity, which may be related to differences in surgeon experience, institutional volume, geographic region, and patient characteristics. In addition, the learning curve may be a critical factor influencing surgical outcomes. Chen et al. (3) reported that surgical performance could improve after overcoming the learning curve of RDP. However, even in high-volume centers, the learning curve for MIDP remains considerably long, requiring approximately 85 cases to achieve proficiency (43). Therefore, mastering MIDP still demands substantial practical experience. Due to the limited number of included studies, subgroup analyses could not be performed. Sensitivity analyses indicated that the results for blood loss, length of hospital stay, operation time, and number of lymph nodes harvested were robust. However, the spleen preservation rate was less stable, and further studies are needed to clarify this outcome. The heterogeneity of patient populations (benign lesions vs. malignant tumors) may influence the study results. Among the included studies, two (3, 6) enrolled only patients with malignant tumors, while five (1, 2, 5, 14, 17) included both benign and malignant cases. However, none provided separate analyses for benign and malignant cohorts. Therefore, we were unable to specifically evaluate the safety and efficacy of RDP in benign vs. malignant disease. Future studies are needed to investigate the outcomes of RDP in more defined patient populations. Apart from robotic surgery, laparoscopy represents another minimally invasive approach. However, the lack of comparative studies involving laparoscopic surgery limits the generalizability of our findings to broader clinical practice. Finally, although our findings suggest potential short-term benefits of RDP, the lack of long-term oncologic outcome data remains a major limitation. Further studies are warranted to comprehensively evaluate its long-term efficacy and oncologic safety.

In conclusion, this meta-analysis indicates that RDP achieves comparable short-term outcomes to ODP while significantly reducing intraoperative blood loss, enhancing splenic preservation, and lowering both SSI rates and length of hospital stay. Given that these findings are derived from non-RCTs, future high-quality RCTs with longer follow-up are warranted to further validate the potential benefits of RDP.