The impact of minimally invasive pancreatic surgery Improving outcome

Keyhole i.e. minimally invasive, including laparoscopy or robotic, surgery has brought a revolutionary change in the surgical field and is associated with less surgical trauma to tissue, less intra-operative blood loss, pain reduction, shorter time to functional recovery and shorter hospital stay. For pancreatic surgery the use of keyhole surgery is still in development. Randomized data, published in recent years created mixed signals. Hereby hampering the widespread dissemination of keyhole pancreatic surgery. This thesis emphasises the importance of understanding the potential drawbacks of the minimally invasive technique by looking into the learning curve of minimally invasive distal pancreatectomy (MIDP), the surgical outcomes following conversion to open surgery during MIDP and minimally invasive pancreatoduodenectomy (MIPD) and in addition into the selection criteria for suitable patients for the minimally invasive technique. Choosing the right patient for the technique is important, as poor selection may result in poor outcome and the described risk factors for conversion should be considered. Furthermore, this thesis describes how keyhole surgery is applied best. It showed that robotic distal pancreatectomy (RDP) has some advantages over laparoscopy in terms of spleen-preservation and conversion rates. Laparoscopic distal pancreatectomy with spleen-preservation results in similar short-term surgical outcomes when compared to laparoscopic distal pancreatectomy with splenectomy. Whether MIDP for pancreatic ductal adenocarcinoma results in comparable oncological outcomes as open surgery will be proven by the DIPLOMA randomized controlled trial. Finally, in order to further improve the outcomes of pancreatic surgery, this thesis highlights the importance of multidisciplinary collaboration.