Pancreaticoduodenectomy (PD) requires the completion of multiple organ resections and complex GI reconstruction, which is a difficult procedure with a high complication rate. Although laparoscopic pancreaticoduodenectomy (LPD) was reported in the early days of laparoscopic technology, the number of hospitals performing LPD is still limited and the number of reported cases is also small [1, 2]. In recent years, surgical robots have quietly emerged in foreign countries, which have raised the precision and feasibility of surgical procedures to a whole new level on the basis of minimally invasive surgery and have attracted widespread attention. The application of surgical robots in cardiothoracic surgery and urology has been reported more frequently, and some units have also innovatively carried out robotic pancreaticoduodenectomy (RPD) with excellent clinical results [3, 4]. This paper provides a systematic analysis and review of RPD. I. Application of laparoscopic pancreaticoduodenectomy In 1992, Gagner completed the first case of LPD, followed by successive case reports of LPD, which confirmed the feasibility of LPD. Due to the immaturity of laparoscopic technology at that time and the incompleteness of applicable surgical instruments, the initially reported results of LPD were not satisfactory. With the development of laparoscopic techniques and the experience gained from the application of laparoscopy in more complex surgeries such as gastrointestinal tract, the number of reported cases of LPD gradually increased from the beginning of this century, and in general, the operative time was significantly shorter than before, the complication rate decreased significantly, and the surgical outcome improved significantly compared with that before. in 2009, Palanivelu et al. reported 75 cases of LPD with an average operative time of 368 In 2010, Kendrick reported 62 cases of LPD with an average operative time of 368 min, an average intraoperative bleeding of 240 mL, and 26 perioperative complications, including 11 cases of pancreatic leakage, 7 cases of delayed gastric emptying disorder, 5 cases of bleeding, and 2 cases of deep vein thrombosis. There were 26 perioperative complications, including 11 cases of pancreatic leakage, 7 cases of delayed gastric emptying disorder, 5 cases of bleeding, 2 cases of deep vein thrombosis, 1 case of death, and an average postoperative hospital stay of 7 d [6]. In China, the earliest and most completed cases were carried out by Lu Pang Yu et al. at the First Affiliated Hospital of Guangxi Medical University, who completed 32 cases of LPD between 2002 and 2010, with an operative time of 300-600 min, intraoperative bleeding of 300-2000 mL, postoperative hospital stay of 10-53 d, 8 cases (25%) of perioperative complications, and 2 cases (6.25%) of death [7 ]. Currently, LPD is still the most controversial laparoscopic procedure, as demonstrated by the safety and feasibility of LPD. A recent meta-analysis of 285 LPD cases worldwide showed that the surgical complications of LPD are closely related to the operator’s technique, and that for specialists with advanced laparoscopic skills, LPD is technically feasible, and the safety and immediate and long-term results of the procedure are comparable to those of open surgery [8 ]. However, for the vast majority of surgeons, the technical chasm of LPD is still difficult to cross. ②Whether LPD is truly minimally invasive LPD exhibits some characteristics of minimally invasive surgery, such as small incisions, mild postoperative pain, and rapid recovery, but the operative time of LPD is significantly longer, especially in the early stage of its development. The minimally invasive advantages of LPD as a whole have been doubly questioned, and there is still a lack of strong experimental study results to confirm. ③Whether LPD can achieve the requirement of radical tumor cure. Ensuring sufficient surgical margins and thorough lymph node dissection are the basic requirements for radical tumor treatment. In LPD, due to the close relationship between the pancreatic barb and the superior mesenteric vessels, complete laparoscopic resection of the barb is difficult, and there may be partial residuals when this operation is carried out in the early stage, which becomes a source of local recurrence. In addition, laparoscopic skeletonization of the hepatoduodenal ligament and lymph node dissection around the head of the pancreas can be difficult due to the relatively fixed laparoscopic field of view and the limitation of operating angle. whether the long-term efficacy of LPD can reach that of open surgery remains to be verified by a large sample of randomized controlled studies. The dilemma faced by LPD is related to the limitations of laparoscopic technology itself: (1) the operator relies on the assistant to hold the mirror and assist the operation, and the stability of the assistant’s operation is uncertain; (2) the operative field is imaged in a two-dimensional plane, which reduces the hand-eye coordination of the operator’s operation; (3) there is little freedom of movement of surgical instruments, and coupled with counter-intuitive reverse instrumentation, it is difficult to complete fine separation, suturing, anastomosis, and other operations; (4) the learning curve of complex surgery is The learning curve of complex surgery is long, etc. These have become “bottlenecks” in the development of laparoscopic technology, which also limit the development of more technically demanding surgeries such as LPD, and this situation is difficult to be solved in a short time. The technical advantages of da Vinci surgical robot The development direction of surgery in the 21st century is to preserve the physiological structure and function of the patient as much as possible while treating. In order to break through these limitations of laparoscopic technology and to better popularize and promote minimally invasive techniques, new research and exploration have been started. After the early mirror-holding robot (AESOP) and the simple surgical operation robot (ZEUS), the da Vinci surgical system (DVSS), which fully combines the advanced technologies developed by NASA and many research institutions, was introduced at the end of the last century and was approved for clinical use by the FDA in 2000. The DVSS has been continuously updated and developed, and is now in its fourth generation. In addition to inheriting the advantages of minimally invasive laparoscopic surgery, DVSS embodies unprecedented superiority in technology [9]: ① the laparoscopic surgical field of view and surgical operation are controlled by the operator, with good coordination; ② the simulated wrist on the surgical instruments at the end of the system has 7 degrees of freedom of movement, which is more flexible, surpassing the limits of the human hand and improving the accuracy of surgery; ③ the surgical instruments can filter out the natural tremor of the human hand during surgery, reducing misoperation and increasing surgical stability; ③ the surgical instruments can filter out the natural tremor of the human hand during surgery. (3) during surgery, the surgical instruments can filter out the natural flutter of the human hand, reducing misoperation and increasing surgical stability; (4) the surgical instruments are exquisitely constructed, facilitating the completion of fine surgical operations in a small space; (5) the high-resolution 3D image processing equipment surpasses the limits of the human eye, helping the operator to clearly and precisely locate tissues and operate instruments; (6) the operator can operate the system in a seated position, facilitating long and complex operations; (7) with the help of the signal transmission system, making remote consultation and surgery becomes possible. In foreign countries, DVSS has become the best choice for completing complex major surgery and is increasingly used in clinical practice with good results.DVSS can complete minimally invasive surgical operations in cardiothoracic surgery more precisely without destroying the integrity of the thorax, and total intracavitary heart bypass and mitral valve valvuloplasty are representative surgeries, and clinical application shows that the surgical effect of DVSS is significantly better than that of open surgery and thoracoscopic surgery [ 10]. DVSS is used in radical prostate cancer surgery to reduce the impact of surgery on patients’ sexual life and reduce the incidence of postoperative incontinence while ensuring the effect of tumor resection [11], and in Northern Europe, more than half of radical prostate cancer surgeries have been performed by DVSS, and in the United States, this percentage has been reported to be as high as 90%. DVSS is also used in abdominal surgeries, such as complex liver and biliary surgery, gastric bypass bariatric surgery, radical surgery for gastric and colorectal cancer, etc [12-14], DVSS was initially used for local excision of benign pancreatic tumors and caudal pancreatic body surgery, and in recent years, it has been reported to be used in complex pancreatic surgery, and satisfactory results have been achieved [15,16]. Third, the application of surgical robotic pancreaticoduodenectomy On the basis of the previous surgical robotic pancreatic surgery, RPD has been carried out in some large specialized medical centers abroad, among which the earliest reported and the largest number of cases is the surgical team led by Giulianotti at the University of Illinois, U.S.A. In 2010, Giulianotti et al. reported the largest group of surgical robot-assisted pancreatic surgery [17], from October 2000 to January 2009, the authors performed 134 cases of various types of surgical robot-assisted pancreatic surgery, including 60 cases of RPD, with an average patient age of 57 years, an average operating time of 331 min, an average hospital stay of 9.3 d, 14 cases of intermediate open surgery (10.5%), a postoperative complication rate of 26 The perioperative mortality rate was 2.2%. The authors concluded that surgical robots can simplify difficult operations in minimally invasive pancreatic surgery, and that surgical robotic-assisted pancreatic surgery is safe and feasible, and it can achieve the same results as open surgery with minimal invasion. In a recent conference exchange, Giulianotti’s surgical team reported having completed 110 cases of RPD with an average operative time of about 5h, which is no longer different from open surgery, a continuous decrease in surgical complication rates, no perioperative deaths in nearly 60 cases, and a reduction in overall hospital costs that are close to those of open surgery. The results of RPD in the elderly [18], a total of 41 cases, 15 in the over-70 group and 26 in the control group under 70 years of age, showed no significant differences between the two groups in terms of operative time, intermediate open rate, postoperative complication rate, perioperative mortality, and mean length of hospital stay, and the results suggest that RPD is safe even for elderly patients over 70 years of age. Therefore, age is no longer an independent contraindication for RPD in skilled surgeons. Recently, Giulianotti et al. reported two cases of pancreatic head cancer with portal vein invasion and successful robotic-assisted enlargement of RPD [19], in which pancreaticoduodenectomy, partial resection and reconstruction of the portal vein were performed robotically, and the whole procedure was smooth, lasting 392 min, with an intraoperative bleeding of about 200 ml and a good postoperative recovery, with a 6-month follow-up, and still in tumor-free He is still alive and well. Zureikat et al. at the University of Pittsburgh recently reported 30 cases of da Vinci surgical robot-assisted major pancreatic resection and reconstruction, including 24 cases of RPD [20], resulting in a mean operative time of 512 min, intraoperative bleeding of 320 ml, mean hospital stay of 9 d, postoperative mortality of 3.3% (1/30), incidence of pancreatic leakage of 27 The authors concluded that surgical robotic-assisted major pancreatic surgery, including RPD, can completely achieve the same results as open surgery for medical units with a large number of pancreatic surgery cases and surgical experience, and the technical advantages of surgical robots will become more and more obvious with the progress of robotic technology and the accumulation of operator experience. Horiguchi et al. of Fujia University, Japan, reported 3 cases of RPD [21], and the authors used the Child method to reconstruct the digestive tract, with an average operating time of 703 min, intraoperative bleeding of 118 ml, and an average hospital stay of 26 d. One case of postoperative pancreatic leakage occurred and was cured by conservative treatment, and the authors concluded that RPD bleeds less, pancreatic-intestinal anastomosis is practically reliable, and the prolonged operating time is believed to be The prolonged operative time is believed to be solved by the accumulation of the operator’s experience. In terms of surgical technique, Narula et al. of Ohio State University proposed a “hybrid” technique combining laparoscopy and surgical robotics to complete RPD [22], and the authors used this technique to complete five cases of pancreatic masses with obstructive jaundice. The procedure was done in two steps, firstly, laparoscopically, the abdominal cavity was explored for metastases in the liver and other areas, the gastrocolic ligament was severed, the pancreas was revealed, the superior mesenteric vein was separated and the possibility of resection was determined. If feasible, the gallbladder is removed laparoscopically, the common bile duct is freed and severed, the stomach is excised, the pancreas is dissected, the pancreatic hook is removed, the jejunum is dissected, and the entire specimen is removed. In the second step, reconstruction of the digestive tract, mucosa-to-mucosa pancreatic-intestinal anastomosis, end-to-side biliary-intestinal anastomosis, and gastrointestinal anastomosis by anastomosis were completed under the surgical robot. The average operative time was 7 h, the average hospital stay was 9.6 d, and the patients were normal at the 6-month postoperative follow-up. The authors concluded that the “hybrid” technique for RPD can simplify the technique and give full play to the advantages of laparoscopy and surgical robot, which is worth promoting. Zhou Ningxin et al. compared the short-term efficacy of da Vinci robot-assisted PD (RPD) with that of open PD [23], and the results showed that the radical tumor cure rates of the two groups were 87.5% and 100%, respectively, with no significant difference, and the mean operating times were 718 min and 420 min, respectively, with the RPD group significantly prolonged. activity time and hospital stay were 27.5h, 16.4d and 96h, 24.3d, respectively, which were significantly shorter in the RPD group, and the surgical complication rates were 25% and 75%, respectively, which were significantly reduced in the RPD group. The authors concluded that the advantages of da Vinci robot-assisted PD are obvious, as shown by the small trauma of surgery, fine intraoperative operation, less bleeding, less postoperative complications, and fast recovery, and the long operation time is due to the early stage carried out by the authors, which can be solved with the accumulation of experience of the surgical team. The development of science and technology continues to promote the progress of surgical methods, which began in the 1980s, and the rapid popularization of minimally invasive technology represented by laparoscopy is an obvious example, and the emergence of surgical robotics in recent years, relying on its unique technical advantages, has expanded the connotation of minimally invasive surgery and greatly improved the precision and feasibility of complex surgery, and has made breakthroughs in some fields, and even It has been predicted that a new era of surgery, represented by surgical robots and marked by information processing, is coming. Compared with traditional PD surgery, LPD reduces surgical trauma and has some characteristics of minimally invasive surgery, but the development of LPD is difficult to promote in the short term due to the limitations of laparoscopic technology itself.RPD can overcome these difficulties, and its advantages are reflected in [24-26]: ① high resolution and magnified three-dimensional field of view, which increases the accuracy of intraoperative dissection, and for lymph node clearance, it can achieve close The lymph nodes of No.12 and No.8, which are difficult to reach under laparoscopy, can be thoroughly cleared, and the exploration, exposure and clearance of the aorta, abdominal arterial trunk, parapancreatic, root of mesenteric vessels and posterior lymph nodes of the head of pancreas can also be completed smoothly. The resection process is more delicate and safer, and in the process of dealing with the hooks, it can easily show the post-portal structure and ensure the complete removal of the hooked part of the pancreas; it also facilitates the reconstruction of the digestive tract, especially the completion of the pancreatic-intestinal anastomosis, and the fine operation reduces the occurrence of side injuries and complications; ③ the feasibility of complex surgery is improved and popularized. It expands the extension of lumpectomy surgery to practical, difficult and high-risk major surgery, and makes the coverage of minimally invasive surgery more extensive and comprehensive in the future. Clinical application results show that. At the same time, we also need to see that RPD also has some shortcomings: ① RPD involves a wide range of surgery, which requires intraoperative movement and conversion between multiple abdominal areas, while DVSS is limited in its operating range after the instrument arm is fixed, and sometimes it is difficult to achieve such requirements, hybridization techniques; ② it takes a long time to carry out early preoperative preparation and intraoperative replacement of instruments and other operations, the adaptation of the operator, the overall operating time prolonged; ③ there are some shortcomings of the surgical robot itself, such as the lack of tactile feedback and the lack of matching and complete surgical instruments available; ④ RPD surgery is significantly more expensive than open and laparoscopic surgery [27], and none of them are covered by various insurances, which becomes an important factor limiting the development of RPD. We believe that with the continuous improvement and development of surgical robots, surgical techniques will become increasingly mature and RPD will be more and more widely performed. In China, with the gradual popularization of surgical robots, more patients will also benefit from RPD.