Minimally invasive versus open pancreatic surgery A critical evaluation of safety and efficacy

This thesis presents a comprehensive and critical evaluation of minimally invasive pancreatoduodenectomy (MIPD), focusing on its safety, efficacy, and implementation in clinical practice. The work combines nationwide and international observational data with results from a randomized controlled trial to assess whether MIPD can be safely adopted and how outcomes compare to the conventional open approach (OPD). With this, it provides an overview of the current state of MIPD and a rationale for its future use and further development.
The first part outlines the limitations of conventional outcome measures in pancreatic surgery and argues for a broader, patient-focused approach that incorporates composite endpoints and oncological quality. This perspective forms the basis for the following studies, using registry data to examine the uptake, outcomes, and variation in practice of MIPD across Europe and worldwide. These analyses reveal significant inter-institutional differences and highlight the importance of structured implementation and outcome monitoring.
Building on these insights, the second part presents the design and results of the DIPLOMA-2 trial. This international, multicenter randomized study compared MIPD and OPD in experienced centers in Europe. The trial demonstrated that MIPD is non-inferior to OPD in terms of major postoperative complications and leads to a faster functional recovery. Additional chapters evaluate the impact of MIPD on costs and the influence of the LEOPARD-2 trial on its use in the Netherlands.
Overall, the findings support adoption of MIPD in experienced, high-volume centers and demonstrate that, with structured training, multidisciplinary collaboration, and continuous outcome evaluation, MIPD can be implemented safely and effectively. This thesis offers a strong foundation for future standards in pancreatic surgery and for the safe, justified expansion of MIPD worldwide.