*Review* **Robotic versus Laparoscopic Surgery for Spleen-Preserving Distal Pancreatectomies: Systematic Review and Meta-Analysis**

**Gianluca Rompianesi , Roberto Montalti \* , Luisa Ambrosio and Roberto Ivan Troisi**

Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Via S.Pansini 5, 80131 Naples, Italy; gianluca.rompianesi@unina.it (G.R.); luisa.ambrosio@unina.it (L.A.); roberto.troisi@unina.it (R.I.T.) **\*** Correspondence: roberto.montalti@unina.it; Tel.: +39-081-7462732

**Abstract:** Background: When oncologically feasible, avoiding unnecessary splenectomies prevents patients who are undergoing distal pancreatectomy (DP) from facing significant thromboembolic and infective risks. Methods: A systematic search of MEDLINE, Embase, and Web Of Science identified 11 studies reporting outcomes of 323 patients undergoing intended spleen-preserving minimally invasive robotic DP (SP-RADP) and 362 laparoscopic DP (SP-LADP) in order to compare the spleen preservation rates of the two techniques. The risk of bias was evaluated according to the Newcastle–Ottawa Scale. Results: SP-RADP showed superior results over the laparoscopic approach, with an inferior spleen preservation failure risk difference (RD) of 0.24 (95% CI 0.15, 0.33), reduced open conversion rate (RD of −0.05 (95% CI −0.09, −0.01)), reduced blood loss (mean difference of −138 mL (95% CI −205, −71)), and mean difference in hospital length of stay of −1.5 days (95% CI −2.8, −0.2), with similar operative time, clinically relevant postoperative pancreatic fistula (ISGPS grade B/C), and Clavien–Dindo grade ≥3 postoperative complications. Conclusion: Both SP-RADP and SP-LADP proved to be safe and effective procedures, with minimal perioperative mortality and low postoperative morbidity. The robotic approach proved to be superior to the laparoscopic approach in terms of spleen preservation rate, intraoperative blood loss, and hospital length of stay.

**Keywords:** robotic distal pancreatectomy; laparoscopic distal pancreatectomy; spleen-preserving distal pancreatectomy; minimally-invasive distal pancreatectomy; systematic review; meta-analysis

## **1. Introduction**

The decision on preserving the spleen when performing a distal pancreatectomy (DP) is usually based on the balance between achieving an adequate oncological clearance and avoiding complications related to asplenia. Spleen-preserving DP has therefore been mainly reserved for surgeries performed for benign indications or to excise lesions with a low malignant potential. With the advent of minimally invasive surgery, in the early 1990s, surgeons around the world started to explore the potential of the laparoscopic approach in pancreatic surgery [1,2] and, almost a decade later, of the robotic-assisted technique [3]. Minimally invasive pancreatic surgery has been progressively gaining widespread popularity, and advancements in surgical skills have removed most of the technical restrictions, allowing the safe and effective execution of complex procedures, including laparoscopic spleen-preserving distal pancreatectomy (SP-LADP) [4] and robotassisted spleen-preserving distal pancreatectomy (SP-RADP) [5].

This systematic review and meta-analysis aims to summarize all of the available evidence regarding spleen-preserving DP and compare results and outcomes of minimally invasive SP-RADP and SP-LADP techniques.

**Citation:** Rompianesi, G.; Montalti, R.; Ambrosio, L.; Troisi, R.I. Robotic versus Laparoscopic Surgery for Spleen-Preserving Distal Pancreatectomies: Systematic Review and Meta-Analysis. *J. Pers. Med.* **2021**, *11*, 552. https://doi.org/10.3390/ jpm11060552

Academic Editor: Marco Milone

Received: 29 April 2021 Accepted: 9 June 2021 Published: 13 June 2021

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#### **2. Materials and Methods**

This systematic review and meta-analysis was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA 2020 Statement [6]) and was registered on PROSPERO (CRD42021239032).

#### *2.1. Search Strategy*

MEDLINE, Embase, and Web Of Science electronic databases were searched using the following terms: "pancrea\*" AND "robot\*" AND "laparoscop\*" AND "sple\*". The last search was run on 1 February 2021 with no language or publication status restrictions. Additional potentially relevant studies were identified from the reference lists of selected studies.

### *2.2. Study Selection*

For inclusion, studies had to (1) include patients undergoing DP for any disease; (2) include procedures performed robotically and laparoscopically; and (3) report data on patients undergoing DP with the intent of preserving the spleen. Case reports, reviews, and communications, as well as non-human studies, were excluded. Two reviewers (G.R. and L.A.) independently screened the results of the electronic search at title and abstract levels. The full texts of the selected references were also retrieved for further analysis and data extraction. When duplicate reports from the same study were identified, only the most recent publication was included.

### *2.3. Data Extraction and Quality Assessment*

Two reviewers (G.R. and L.A.) extracted data from each selected study regarding the first author; publication year; country of origin; study design; number of patients undergoing SP-RADP and SP-LADP; patients characteristics (age, sex, body mass index (BMI)); underlying disease requiring DP; American Society of Anesthesiologists (ASA) score; tumor size; conversion rate; blood loss; pancreatic stump closure technique; splenic vessel preservation and technique (Warshaw vs. Kimura); blood transfusion requirement; length of surgery; data on postoperative morbidity, including prevalence and grading of the clinical severity of postoperative pancreatic fistula (POPF) according to the ISGPS definition [7]; complications and grading according to the Clavien–Dindo classification [8]; re-operation rate; length of stay (LOS); mortality; and length of follow-up. The quality and risk of bias of each included study was evaluated independently by two reviewers (G.R. and L.A.) according to the Newcastle–Ottawa Scale for evaluating the quality of non-randomized studies in meta-analyses [9]. The level of evidence was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system [10]. Any disagreement was resolved through discussion in order to reach consensus across the study team.
