REV I EW Open Access Robotic and laparoscopic surgery of the pancreas: an historical review Alan Kawarai Lefor Abstract Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians. Keywords: Pancreas, Cancer, Laparoscopy, Robotic surgery Background “ Eat when you can, Sleep when you can Don ’ t mess with pancreas ” These succinct “ three rules of surgery ” represent how pancreatic surgery stands apart from other areas of Gen- eral Surgery and the reverence (and fear) that genera- tions of surgeons have had for this organ [1, 2]. Surgery of the pancreas (open, laparoscopic or robotic) is a tech- nical challenge. The purpose of this review is to examine the role of robotic surgery as it is now practiced in the management of lesions of the pancreas. Robotic surgery is the third level of a three-story structure, with laparo- scopic surgery as the second level, and everything built on a foundation of open surgery. We will use history as the guide as we ascend this three-story structure, start- ing with open surgery of the pancreas, then to laparo- scopic surgery and laparoscopic surgery of the pancreas, then robots and robotic surgery and finally to robotic surgery of the pancreas. We need a vision of where we have been in this field to understand how we reached the point we are at today. Correspondence: [email protected] Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan BMC Biomedical Engineering © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lefor BMC Biomedical Engineering (2019) 1:2 https://doi.org/10.1186/s42490-019-0001-4 JULY 2021 | The Surgical Technologist | 303