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nodes were also similar, leading the authors to conclude that the two techniques have similar results. In an unmatched retrospective review, Asbun reported 53 laparoscopic PD compared with 215 open PD and found significantly decreased blood loss and hospital stay in patients undergoing laparoscopic PD. [13] A meta-analysis of 12 comparative studies showed similar results with decreased blood loss and shorter hospital stay [14]. This meta-analysis also reported that some studies have shown higher mortality in patients under- going laparoscopic PD compared with open PD, and this was attributed to procedures performed at low volume centers. The authors reported that five studies compared oncologic outcomes and one study reported that patients undergoing laparoscopic PD received adjuvant therapy earlier and had lower rates of local recurrence with over- all survival similar to patients undergoing open PD. A recent review specifically looked at short-term onco- logic outcomes as well as overall survival [15]. The au- thors reviewed 828 patients who underwent laparoscopic PD and 7385 who underwent open PD from 2010 to 2013 using data from the National Cancer Data Base (US). The two groups were similar in terms of demo- graphics and tumor characteristics. Using a multivariable model adjusted for hospital volume, laparoscopic PD was associated with a trend toward a shorter hospital stay ( p < 0.14). The two groups had similar resection margin status, number of lymph nodes resected and perioperative mortality. Median overall survival was similar in the two groups. Evaluation of laparoscopic PD by an expert panel is es- pecially enlightening [14]. These experts concluded that laparoscopic PD is not a passing fancy but a technique that is here to stay. Training in this advanced procedure is essential. They feel it should be used as an approach in properly selected patients, and that intraoperative conversion to open surgery is not a complication. These experts also presented a list of “ pros ” and “ cons ” of both open and laparoscopic PD (Table 1). The role of high-volume centers in the conduct of lap- aroscopic PD has been examined [10]. A recent analysis of 7061 patients from the National Cancer Database showed that a majority of laparoscopic PDs were per- formed at low-volume centers, with less than 10 proce- dures per 2 years. This review found a significantly higher 30-day mortality rate compared with open PD al- though number of lymph nodes and status of surgical margins were similar. The authors describe a modular- ized training program for laparoscopic PD which in- cludes four phases: Beginner (basic procedures and approach), Intermediate (Kocher maneuver, lesser sac, superior mesenteric vein tunnel), Advanced (dissection and division of major structures, anastomoses) and Ex- pert (Pancreatic anastomosis). This defined teaching model may serve as a model for training in many other surgical techniques, particularly in robotic surgery. As this procedure has become more widespread and less of a technical curiosity, investigators are focusing on complications associated with the procedure. Kantor and colleagues used data from the ACS-NSQIP data base [16]. Of 7907 patients undergoing PD, 1277 had PD per- formed using minimally invasive surgery approaches in- cluding 776 robotic or laparoscopic, 344 hybrid procedures and 197 unplanned conversions. Patients undergoing minimally invasive PD were less likely to have malignant lesions. The 30-day morbidity was less in the minimally invasive surgery group but 30-day mortal- ity and length of stay were similar. They found a higher rate of postoperative pancreatic fistulas in the minimally invasive surgery group, but in conclusion they attribute this to case selection bias and do not feel it is inherent to the minimally invasive surgery approach. Dokmak and colleagues reviewed 46 laparoscopic and 46 open PDs performed at one center from 2011 to 14 [17]. They Table 1 Advantages and disadvantages of laparoscopic and open PD (adapted from 14) Open Minimally Invasive Advantages Standard and well-known Reduced blood loss Operative Time Reduced pain Operative Cost Reduced wound complications Established training Reduced hospital stay Tactile Feedback More rapid recovery Magnified view Computer enhanced motion Disadvantages Blood loss New approach Incisional pain Increased operating time Wound morbidity Equipment cost Hospital Stay Loss of haptic feedback Recovery time Lack of training opportunities Lefor BMC Biomedical Engineering (2019) 1:2 Page 4 of 15 | The Surgical Technologist | JULY 2021 306