mariuscomper.ukRO
Hepato-pancreato-biliary surgery · randomised trials 2017–2026

The robot has reached the liver and pancreas. What have the trials actually shown?

Laparoscopic liver surgery has solid randomised evidence; the robot is only beginning to gather its own. In the pancreas, the story runs from the halted LEOPARD-2 trial to the favourable robotic trials published since 2024.

The trial map

The randomised trials on one screen

Each circle is a published randomised trial: minimally invasive against open surgery, or robot against laparoscopy. Size shows the number of patients randomised; colour shows what happened to the primary endpoint. Tap a circle for details.

Minimally invasive better on the primary endpointNo difference / non-inferiorStopped for safety
Primary endpoints differ between trials (complications, functional recovery, length of stay, R0 resection, quality of life), so the verdicts do not add up. A few small trials, mostly single-centre, from China, Egypt and Japan, with laboratory or loosely defined primary endpoints, are not on the map. TJDBPS02 (laparoscopic pancreatoduodenectomy for pancreatic adenocarcinoma) has 5-year overall survival as its primary endpoint, which is not yet available1; that is why it is drawn as an open circle.

Every figure is taken word for word from the published abstracts. Tap the small number next to any of them 2 to see the original sentence, with links to PubMed and the DOI.

Chapter 1 · Liver

Laparoscopy has passed the randomised test

19% vs 31%30-day complications, laparoscopic vs open, in OSLO-COMET2
4 vs 5 daysto functional recovery after hemihepatectomy, in ORANGE II PLUS3
54% vs 55%5-year survival, laparoscopic vs open, OSLO-COMET4

In 2014, the Morioka consensus conference still split laparoscopic liver resection in two: minor resections had become standard practice (IDEAL 3), while major ones were still innovative procedures in the exploration phase (IDEAL 2b).5 What followed is rare in surgery: randomised trials that actually answered the question.

Minor and parenchyma-sparing resections

OSLO-COMET randomised 280 patients with colorectal liver metastases to laparoscopic (n = 133) or open (n = 147) resection. Every resection was parenchyma-sparing.2 Complications within 30 days occurred in 19% after laparoscopy and 31% after open surgery.2 Hospital stay fell from 96 to 53 hours, with no difference in blood loss, operating time or margins.2

LapOpHuva found the same signal: overall morbidity of 11.5% vs 23.7%, with similar severe complications.6

For a surgical oncologist the real question is different: is anything lost in the long run? In OSLO-COMET, 5-year survival was 54% after laparoscopy and 55% after open surgery.4 The authors are candid about the limit: differences of up to about 10 percentage points in either direction cannot be excluded.4

The hard-to-reach segments

A subgroup of OSLO-COMET looked separately at tumours in the posterosuperior segments: 136 patients, 62 laparoscopic and 74 open.7 Complications were 26% vs 31%7, and hospital stay was 2 days instead of 4.7

The question then got a trial of its own. ORANGE Segments randomised 251 patients8 with tumours in segments 4a, 7 or 8, in 17 centres.8 Functional recovery took 3 days after laparoscopy and 4 after open surgery8, less than the two-day difference the authors had anticipated.8 The R0 rate was comparable (87.7% vs 85.8%).8 There were 3 deaths within 90 days after laparoscopy and one after open surgery (2.5% vs 0.8%), a non-significant difference.8 Tap a segment in the diagram.

Couinaud segments, schematic anterior view

The liver seen from the front: the right lobe is on the left of the picture. The three hepatic veins (blue) separate the sectors, and the dotted line is the portal plane. Segment 1 (caudate) lies posteriorly, beside the vena cava. Hatched segments are the posterosuperior ones. Not to scale.

Choose a segment

The diagram is for teaching: real planes are curved and vary from patient to patient. The reference terminology is Brisbane 2000, extended by the “Tokyo 2020” terminology.9

Major hepatectomy

ORANGE II PLUS randomised 352 patients for hemihepatectomy, of whom 332 underwent surgery3, in 16 European hospitals.3 Median functional recovery took 4 days after laparoscopy and 5 after open surgery3, with similar major complications (14.5% vs 16.9%).3 In cancer patients, adjuvant treatment started sooner: after 46.5 days rather than 62.8.3 The R0 rate was 77.9% vs 84.1%, a difference that was not statistically significant but that a surgeon will notice.3

A post-hoc analysis of right hepatectomy alone (105 laparoscopic, 108 open)10 shows a smaller gain: hospital stay of 5 vs 6 days10, with longer operations (332 vs 263 minutes).10

The European Southampton guidelines (2017) set out 67 statements on laparoscopic liver surgery.11 They were followed in 2025 by the internationally validated European Brescia guidelines.12
Chapter 2 · The robot in the liver

Against laparoscopy: a single randomised trial, and a small one

80patients in ROC'N'ROLL, the only randomised robot-vs-laparoscopy trial in this review13
13% vs 37%severe complications after robotic vs laparoscopic anatomical hepatectomy, exploratory post-hoc analysis14
≤8.2%benchmark conversion rate for robotic right hepatectomy, from 22 centres15

ROC'N'ROLL, run at a single academic centre13, randomised 80 patients with malignant liver tumours to robotic (n = 41) or laparoscopic (n = 39) resection.13 The primary endpoint, the mean role-functioning score (quality of life) over the first 90 days after surgery, did not differ (74.3 vs 79.6).13 Nor did the comprehensive complication index (CCI) differ significantly: 8.9 vs 15.5.13

The most interesting figure comes from a post-hoc analysis of the 57 anatomical hepatectomies.14 Severe complications occurred in 13% after robotic and 37% after laparoscopic surgery14, even though the robotic cases were harder (median IWATE score 10 vs 7).14 The result remains a hypothesis: no sample size was calculated for the subgroup.14

What we have instead of trials: benchmarks

A study from 22 expert centres set reference values for robotic right hepatectomy, computed on the 172 of 357 patients at low risk.15 The thresholds are: operating time ≤476 minutes, conversion ≤8.2%, bile leak ≤15.4% and major complications ≤23.1%.15 The 2023 international consensus guideline on robotic liver resection, written by 29 experts, has 14 recommendations, only 8 of which could be formulated with the GRADE method.16

Chapter 3 · Distal pancreatectomy

Here the question has been answered

4 vs 6 daysto functional recovery, minimally invasive vs open, in LEOPARD17
73% vs 69%R0 resection in pancreatic cancer, in DIPLOMA (non-inferior)18
32 vs 34 monthsmedian survival, long-term DIPLOMA, HR 1.0219

In LEOPARD, run in 14 Dutch centres20, patients did not know which approach they had received: the incisions were hidden under a large abdominal dressing.17 Functional recovery took 4 days after the minimally invasive approach and 6 after the open one.17 Grade B/C delayed gastric emptying was less frequent (6% vs 20%).17 One detail worth keeping in mind: grade B/C pancreatic fistula was 39% vs 23%, a difference that was not statistically significant (P = 0.07).17 LAPOP, with 60 randomised patients21, confirmed the benefit: a hospital stay of 5 vs 6 days21 and functional recovery in 4 vs 6 days.21

The oncological test: DIPLOMA

DIPLOMA randomised 258 patients with resectable pancreatic adenocarcinoma18 in 35 centres in 12 countries.18 Both patients and pathologists were blinded to the approach. R0 resection (margin ≥1 mm) was achieved in 73% after the minimally invasive approach and 69% after the open one18, within the non-inferiority margin of −7%.18 The lymph node yield was practically identical: 22 vs 23.18

The long-term results, published in 2025 after a median follow-up of 38 months19, settle the matter: median survival of 32 vs 34 months (HR 1.02)19 and disease-free survival of 21 vs 17 months.19 Adjuvant treatment reached patients just as often: 70% vs 72%.19

CSPAC-2, a trial from 6 Chinese centres22, randomised 306 patients with left-sided pancreatic cancer to laparoscopic or open surgery22, with recurrence-free survival as the primary endpoint.22 Laparoscopy brought no oncological benefit: a median of 15.5 vs 15 months.22 The R0 rate was 88.5% vs 89.1%.22

The benchmark for robotic distal pancreatectomy (16 centres, 755 cases)23 sets conversion at ≤3%23, while laparoscopy had 5 times as many conversions in comparison.23 After a median follow-up of 44 months, LEOPARD patients operated on with the minimally invasive approach were more satisfied with how their scar looked (21 vs 14 points).20

Chapter 4 · Laparoscopic pancreatoduodenectomy

The lesson of LEOPARD-2

10% vs 2%complication-related 90-day mortality, laparoscopic vs open: trial stopped24
15% → 1%share of laparoscopic Whipples in the Netherlands in the following years; robotic rose from 0% to 25%25
15 vs 16 dayshospital stay in TJDBPS01 (656 patients): a “marginal” benefit26

The first two trials were small, single-centre and positive. PLOT (64 patients)27 reported a hospital stay of 7 days against 13.27 PADULAP (66 patients)28 reported 13.5 vs 17 days28, but with much longer operations (486 vs 365 minutes)28 and a conversion rate of 23.5%.28

LEOPARD-2 was the multicentre test. Its entry criteria looked strict: centres doing at least 20 pancreatoduodenectomies a year, surgeons with a dedicated training programme and at least 20 laparoscopic pancreatoduodenectomies already done.24 Already in phase 2, 3 of 20 patients died within 90 days after the laparoscopic approach, against none of 20 after open surgery.24 The trial continued, but after 105 randomised patients the safety board stopped it: 5 complication-related deaths in 50 (10%) after laparoscopy, against 1 in 49 (2%) after open surgery.24 Functional recovery was not even faster: 10 vs 8 days.24

The Netherlands drew the conclusion nationally29. During the LAELAPS-3 programme, laparoscopic pancreatoduodenectomy fell from 15% to 1% and robotic rose from 0% to 25%.25

China and Korea: very large experience, small gain

TJDBPS01 randomised 656 patients26 in 14 Chinese centres26, operated on by surgeons with at least 104 laparoscopic pancreatoduodenectomies behind them.26 Hospital stay was one day shorter: 15 vs 16 days.26 The authors themselves call the clinical benefit “marginal” despite extensive procedural expertise.26 At 3 years, survival for malignant disease was 59.1% vs 54.3%, with no significant difference.30 A trial from seven tertiary centres31, with 252 patients,31 gained a little over a day of recovery: 7.7 vs 9.0 days.31

The 2026 meta-analysis of the ten randomised trials of minimally invasive pancreatoduodenectomy (1794 patients)32 concludes that the minimally invasive approach brought no clinically relevant advantage over open surgery, in either its robotic or its laparoscopic form.32

Chapter 5 · Robotic pancreatoduodenectomy

Since 2024, robotic trials have begun to show an advantage

−3.9 daysto functional recovery, robotic vs open, in PORTAL (BMJ)33
22.6% vs 35.7%pancreatic fistula, minimally invasive vs open, in DIPLOMA-234
4.7% vs 2.0%90-day mortality in DIPLOMA-2; the confidence interval is very wide34

Liu et al. (Lancet Gastroenterology & Hepatology, 2024) randomised 164 patients in three high-volume Chinese hospitals, operated on by surgeons past the learning curve (at least 40 robotic and 60 open pancreatoduodenectomies).35 Postoperative hospital stay, the primary endpoint, was shorter after robotic surgery: a median of 11.0 vs 13.5 days.35 Severe complications were similar.35

EUROPA, run at a single high-volume centre36, was the first randomised trial of robotic vs open surgery: 81 patients, of whom only 62 were analysed.36 The comprehensive complication index at 90 days was similar (34.02 vs 36.45).36 Grade B/C pancreas-specific complications, however, were more frequent after robotic surgery (58.6% vs 33.3%)36, and conversion reached 23%.36

DIPLOMA-2 (NEJM Evidence, 2025) randomised 288 patients in 14 centres: 170 robotic, 20 laparoscopic and 98 open.34 Randomisation was 2:1, and patients did not know which approach they had received until postoperative day 5.34 The minimally invasive approach was non-inferior on complications (CCI 33.4 vs 35.3)34, with functional recovery in 7 vs 8 days.34 Pancreatic fistula fell from 35.7% to 22.6%34, and surgical site infection from 22.7% to 12.6%.34 Mortality at 90 days was 4.7% vs 2.0%, with a relative risk of 2.40 and a confidence interval from 0.51 to 11.30.34 An interval that wide can neither confirm nor rule out a higher risk.

The activity trackers worn in DIPLOMA-2 show the benefit lasting beyond discharge: on day 30, patients after minimally invasive surgery walked on average 659 more steps a day.37 By day 90 the difference had gone.37

PORTAL (BMJ, 2026) randomised 268 patients33 in seven high-volume Chinese centres.33 The restricted mean time to functional recovery was 12.1 days after robotic and 16.0 after open surgery (a difference of −3.9 days).33 Hospital stay was 13 vs 16 days33, and Clavien-Dindo grade II or higher complications were 23.5% vs 34.4%.33 Mortality at 90 days was 0.8% vs 2.5%.33

Days to recovery: minimally invasive vs open

Each line joins the minimally invasive and the open value from the same trial. Liver, distal pancreas, laparoscopic and robotic pancreatoduodenectomy.

Minimally invasiveOpen
Definitions differ: most report the median time to functional recovery; Yoon reports the mean; PORTAL reports the restricted mean time (RMET); LAPOP reports median functional recovery as a secondary endpoint. Compare the direction and the gap within each row, not the rows with each other.
Chapter 6 · Learning curve and cost

The robot pays its way through volume and structured training

22robotic pancreatoduodenectomies to the learning-curve inflection point (operating time), in LAELAPS-325
48.6% → 31.8%pancreatic fistula between the first and second half of robotic experience, at a high-volume centre38
+€5491extra intraoperative cost for the robot in DIPLOMA-2; total cost did not differ significantly39

The Dutch LAELAPS-3 programme trained 15 surgeons from seven centres, who performed 275 robotic pancreatoduodenectomies.25 The learning curve for operating time had its inflection point at 22 procedures.25 The European version, LEARNBOT, started in 20 high-volume centres in 12 countries with no previous robotic experience in this operation40 and gathered 486 procedures.40 Conversion was 18.3%40, fistula 21.2%40, and in-hospital or 30-day mortality 2.7%.40 Their conclusion: even after simulation, a learning-curve effect on fistula was still visible at centre level.40

Introducing robotic pancreatoduodenectomy at a high-volume centre: first vs second half

588 consecutive pancreatoduodenectomies at a single centre: 214 robotic, 374 open.38 Each line shows how one measure changed between the earlier and later robotic cases.

The cost per robotic procedure fell from €32 836 to €21 77838, becoming comparable with open pancreatoduodenectomy over the same period (€21 013).38 A post-hoc observational study from a single centre.

In DIPLOMA-2, total cost at 6 months did not differ significantly: €30 956 after robotic and €28 271 after open surgery.39 The probability that the robot was cost-effective within the first 6 months stayed below 30%.39 PORTAL found higher admission costs after robotic surgery.33

For a new programme, the yardstick is the pancreatoduodenectomy benchmark from 23 expert centres41, computed only on patients without significant comorbidities or major vascular resection.41 In these patients the thresholds are: grade B/C fistula 19%, severe complications 30% and failure to rescue 9%.41 In ASA ≥3 patients failure to rescue was 16%, so a programme should only be compared with similar patients.41

Chapter 7 · Pancreatic fistula

The same language for the same complication

The comparisons above only make sense because fistula is defined the same way everywhere. Since 2016, the ISGPS definition requires drain amylase above 3 times the upper limit of normal serum amylase42. The former “grade A fistula” is now called a biochemical leak.42 Answer the three questions below to grade a case.

1. On or after postoperative day 3, is drain-fluid amylase more than 3 times the upper limit of normal serum amylase?
2. Did the fistula change postoperative management? For example: a drain kept beyond 3 weeks, a drain repositioned or newly placed, endoscopically or percutaneously, or antibiotics for infection.
3. Did it lead to reoperation, organ failure or death?
—
Answer the three questions.
The criteria are simplified from the 2016 ISGPS definition.42 The full definition lists every clinical situation for grades B and C; when in doubt, read the paper.

The risk, before it happens

Callery’s fistula risk score (FRS) adds four factors assessed during surgery (small duct, soft pancreas, high-risk pathology, excessive blood loss)43 into a score from 0 to 10, with four risk zones: negligible (0), low (1–2), intermediate (3–6) and high (7–10).43 In the original cohort, patients scoring 0 never developed a clinically relevant fistula, and all those scoring 9 or 10 did.43

The alternative score (a-FRS) drops blood loss and pathology and keeps a soft pancreas (OR 2.58), duct diameter (OR 0.68 per millimetre) and BMI (OR 1.07 per unit).44 Its pan-European validation in minimally invasive pancreatoduodenectomy brought out a technical factor: single-layer pancreatojejunostomy (OR 4.6)45, which the authors say should be avoided.45

The FRS catalogue (5533 pancreatoduodenectomies from 17 institutions)46 identified two scenarios of increased vulnerability within the intermediate-risk zone.46 In these scenarios, using the recommended strategies together was associated with fistula in 10.7% of patients, against 35.5% without them. The comparison is observational, not randomised.46

Chapter 8 · From Fundeni, Bucharest

The same logic in the published work of a Bucharest centre

The ideas in these trials have counterparts in the published case work of the “Dan Setlacec” Centre of General Surgery and Liver Transplantation at Fundeni Clinical Institute in Bucharest, Romania. OSLO-COMET randomised exactly the kind of surgery the Fundeni school argues for: resections that spare liver parenchyma.

“In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors.”47Botea F, Bârcu A, Kraft A, Popescu I, Linecker M · Medicina (Kaunas) 2022

Klatskin tumour and segment 1

Bârcu A et al. · Chirurgia (Bucur) 2021
A Bismuth-Corlette type IIIb Klatskin tumour48 was treated by left hepatectomy with en-bloc resection of the whole of segment 1. The patient was disease-free at 84 months.48 The authors’ recommendation: if the tumour infiltrates the bile ducts of segment 1, the whole segment should be removed.48

Repeated ultrasound-guided resections

Kraft A, Bârcu A et al. · Chirurgia (Bucur) 2023
An ultra-low robotic anterior resection performed together with multiple ultrasound-guided liver resections, by open approach.49 In all, 32 liver metastases were treated.49 Survival was 34 months from the first operation.49

Salvage hepatectomy for GIST

Kraft A, Moldovan C, Bârcu A et al. · Life (Basel) 2023
The disease had not responded after 31 months of tyrosine-kinase inhibitors.50 After a two-stage debulking resection, the patient lived 55 months, a postoperative survival benefit of 25 months.50

Grade V liver trauma

Mitricof B, Kraft A, Anton F, Barcu A et al. · World J Clin Cases 2023
An AAST grade V liver injury with avulsion of the right portal branch and the common bile duct51, free of complications at 55 months.51

The Brisbane 2000 terminology was presented in Romanian in Chirurgia by I. Popescu and I. Câmpeanu.52 For intraoperative ultrasound there is an interactive simulator on the real liver of a patient with colorectal metastases:

Laparoscopic ultrasound on a real patient’s liverIntraoperative ultrasound simulated on a real CT, with a transection plan compared with the resection that was performed.→
Chapter 9 · Still open

Where there is consensus, and where the evidence is still incomplete

ProcedureState of the evidenceThe open question
Minor liver resectionStandardHow small the oncological differences really are.4
Laparoscopic hemihepatectomyRandomised benefitA numerically lower R0 rate in ORANGE II PLUS (NS).3
Robotic vs laparoscopic liverOne small trialThe advantage in difficult anatomical resections is only a hypothesis.14
Distal pancreatectomyOncologically validatedRobot vs laparoscopy: the robotic benchmark has 5 times fewer conversions, but the comparison is not randomised.23
Laparoscopic WhippleMarginal benefit5-year survival in pancreatic adenocarcinoma, not yet available.1
Robotic WhippleFavourable trials since 2024Oncological safety (R0) in pancreatic cancer: DIPLOMA-2x2.53

The next important answer will come from DIPLOMA-2x2: 413 patients with pancreatic cancer or distal cholangiocarcinoma53, with R0 as the primary endpoint and a non-inferiority margin of −7%.53 Its entry criteria show how far the robot still is from routine surgery: surgeons with at least 60 robotic and 60 open pancreatoduodenectomies, and centres doing at least 30 robotic ones a year.53 Enrolment was expected to finish in May 2026.53

The 2019 Miami guidelines on minimally invasive pancreatic resection (28 recommendations)54 were written before DIPLOMA, DIPLOMA-2 and PORTAL. Their next update will, for the first time, have robotic trials to rest on.

References

Sources, in order of appearance

Each reference links to PubMed and to the original article (DOI). The abstracts were retrieved from PubMed on 5 November 2026; the quotations in the text are exact sentences from those abstracts.

  1. TJDBPS02 (PDAC). Wang M, Pan S, Qin T et al.. Short-Term Outcomes Following Laparoscopic vs Open Pancreaticoduodenectomy in Patients With Pancreatic Ductal Adenocarcinoma: A Randomized Clinical Trial. JAMA Surg 2023;158:1245-1253. PubMed 37878305 · DOI
  2. OSLO-COMET. Fretland ÅA, Dagenborg VJ, Bjørnelv GMW et al.. Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial. Ann Surg 2018;267:199-207. PubMed 28657937 · DOI
  3. ORANGE II PLUS. Fichtinger RS, Aldrighetti LA, Abu Hilal M et al.. Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. J Clin Oncol 2024;42:1799-1809. PubMed 38640453 · DOI
  4. OSLO-COMET, 5 ani. Aghayan DL, Kazaryan AM, Dagenborg VJ et al.. Long-Term Oncologic Outcomes After Laparoscopic Versus Open Resection for Colorectal Liver Metastases : A Randomized Trial. Ann Intern Med 2021;174:175-182. PubMed 33197213 · DOI
  5. Morioka 2014. Wakabayashi G, Cherqui D, Geller DA et al.. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015;261:619-29. PubMed 25742461 · DOI
  6. LapOpHuva. Robles-Campos R, Lopez-Lopez V, Brusadin R et al.. Open versus minimally invasive liver surgery for colorectal liver metastases (LapOpHuva): a prospective randomized controlled trial. Surg Endosc 2019;33:3926-3936. PubMed 30701365 · DOI
  7. OSLO-COMET, segmente postero-superioare. Aghayan DL, Fretland ÅA, Kazaryan AM et al.. Laparoscopic versus open liver resection in the posterosuperior segments: a sub-group analysis from the OSLO-COMET randomized controlled trial. HPB (Oxford) 2019;21:1485-1490. PubMed 30962136 · DOI
  8. ORANGE Segments. Sijberden JP, Kuemmerli C, Ratti F et al.. Laparoscopic versus open parenchymal preserving liver resections in the posterosuperior segments (ORANGE Segments): a multicentre, single-blind, randomised controlled trial. Lancet Reg Health Eur 2025;51:101228. PubMed 40060302 · DOI
  9. Tokyo 2020. Wakabayashi G, Cherqui D, Geller DA et al.. The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system. J Hepatobiliary Pancreat Sci 2022;29:6-15. PubMed 34866349 · DOI
  10. ORANGE II PLUS, hepatectomie dreaptă. Olij B, Pilz da Cunha G, Ratti F et al.. Laparoscopic versus open hemihepatectomy: does side matter? A post-hoc analysis of the ORANGE II PLUS randomized controlled trial. Surg Endosc 2026;40:4195-4205. PubMed 41803352 · DOI
  11. Southampton 2017. Abu Hilal M, Aldrighetti L, Dagher I et al.. The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Ann Surg 2018;268:11-18. PubMed 29064908 · DOI
  12. Brescia 2025. Abu Hilal M, Hoogteijling TJ, Edwin B et al.. The Brescia internationally validated European guidelines on minimally invasive liver surgery. Br J Surg 2025;112. PubMed 40568914 · DOI
  13. ROC'N'ROLL. Birgin E, Heibel M, Hetjens S et al.. Robotic versus laparoscopic hepatectomy for liver malignancies (ROC'N'ROLL): a single-centre, randomised, controlled, single-blinded clinical trial. Lancet Reg Health Eur 2024;43:100972. PubMed 39210947 · DOI
  14. ROC'N'ROLL, hepatectomii anatomice. Birgin E, Heibel M, Hetjens S et al.. Robotic versus laparoscopic anatomical hepatectomy: a post hoc analysis of the ROC'N'ROLL randomized controlled trial. Surg Endosc 2026. PubMed 42811178 · DOI
  15. Benchmark hepatectomie dreaptă robotică. Müller PC, Aegerter NLE, Billeter AT et al.. International Benchmark Values for Robotic Right Hepatectomy: Multicenter Study From 22 Expert Centers. Ann Surg Open 2025;6:e625. PubMed 41451175 · DOI
  16. Consens rezecție hepatică robotică 2023. Liu R, Abu Hilal M, Wakabayashi G et al.. International experts consensus guidelines on robotic liver resection in 2023. World J Gastroenterol 2023;29:4815-4830. PubMed 37701136 · DOI
  17. LEOPARD. de Rooij T, van Hilst J, van Santvoort H et al.. Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial. Ann Surg 2019;269:2-9. PubMed 30080726 · DOI
  18. DIPLOMA. Korrel M, Jones LR, van Hilst J et al.. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. Lancet Reg Health Eur 2023;31:100673. PubMed 37457332 · DOI
  19. DIPLOMA, rezultate pe termen lung. Bruna CL, van Hilst J, Korrel M et al.. Minimally Invasive vs Open Left Pancreatectomy for Resectable Pancreatic Cancer: Long-Term Results of the Randomized DIPLOMA Trial. JAMA Surg 2025;160:1299-1307. PubMed 41060640 · DOI
  20. LEOPARD, calitatea vieții la 3 ani. Korrel M, Roelofs A, van Hilst J et al.. Long-Term Quality of Life after Minimally Invasive vs Open Distal Pancreatectomy in the LEOPARD Randomized Trial. J Am Coll Surg 2021;233:730-739.e9. PubMed 34530127 · DOI
  21. LAPOP. Björnsson B, Larsson AL, Hjalmarsson C et al.. Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial. Br J Surg 2020;107:1281-1288. PubMed 32259297 · DOI
  22. CSPAC-2. Liu C, Cheng H, Wang M et al.. Effect of Laparoscopic Versus Open Distal Pancreatectomy on Recurrence-free Survival in Patients With Left-sided Pancreatic Cancer: A Randomized Controlled Trial. Ann Surg 2025;282:930-938. PubMed 39996303 · DOI
  23. Benchmark pancreatectomie distală robotică. Müller PC, Breuer E, Nickel F et al.. Robotic Distal Pancreatectomy: A Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers. Ann Surg 2023;278:253-259. PubMed 35861061 · DOI
  24. LEOPARD-2. van Hilst J, de Rooij T, Bosscha K et al.. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol 2019;4:199-207. PubMed 30685489 · DOI
  25. LAELAPS-3. Zwart MJW, Nota CLM, de Rooij T et al.. Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3). Ann Surg 2022;276:e886-e895. PubMed 33534227 · DOI
  26. TJDBPS01. Wang M, Li D, Chen R et al.. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 2021;6:438-447. PubMed 33915091 · DOI
  27. PLOT. Palanivelu C, Senthilnathan P, Sabnis SC et al.. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg 2017;104:1443-1450. PubMed 28895142 · DOI
  28. PADULAP. Poves I, Burdío F, Morató O et al.. Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Ann Surg 2018;268:731-739. PubMed 30138162 · DOI
  29. de Graaf et al. 2025. de Graaf N, Festen S, Besselink MG et al.. Nationwide practice change after early termination of a randomised trial of laparoscopic pancreatoduodenectomy. Lancet Gastroenterol Hepatol 2025;10:791-792. PubMed 40782812 · DOI
  30. TJDBPS01, 3 ani. Qin T, Zhang H, Pan S et al.. Effect of Laparoscopic and Open Pancreaticoduodenectomy for Pancreatic or Periampullary Tumors: Three-year Follow-up of a Randomized Clinical Trial. Ann Surg 2024;279:605-612. PubMed 37965767 · DOI
  31. Yoon (Coreea). Yoon YS, Lee W, Kang CM et al.. Laparoscopic versus open pancreatoduodenectomy for periampullary tumors: a randomized clinical trial. Int J Surg 2024;110:7011-7019. PubMed 39172725 · DOI
  32. Toti, meta-analiză RCT 2026. Toti JMA, Roesel R, Billeter AT et al.. Minimally Invasive Versus Open Pancreatoduodenectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ann Surg Open 2026;7:e656. PubMed 42344447 · DOI
  33. PORTAL. Jin J, Qin K, Gemenetzis G et al.. Robotic versus Open Pancreatoduodenectomy (PORTAL): multicentre, single masked, phase 3, non-inferiority randomised controlled trial. BMJ 2026;394:e319692. PubMed 42386316 · DOI
  34. DIPLOMA-2. de Graaf N, Emmen AMLH, Ramera M et al.. Minimally Invasive versus Open Pancreatoduodenectomy for Resectable Neoplasms. NEJM Evid 2025;4:EVIDoa2500045. PubMed 41288428 · DOI
  35. Liu et al. 2024. Liu Q, Li M, Gao Y et al.. Effect of robotic versus open pancreaticoduodenectomy on postoperative length of hospital stay and complications for pancreatic head or periampullary tumours: a multicentre, open-label randomised controlled trial. Lancet Gastroenterol Hepatol 2024;9:428-437. PubMed 38428441 · DOI
  36. EUROPA. Klotz R, Mihaljevic AL, Kulu Y et al.. Robotic versus open partial pancreatoduodenectomy (EUROPA): a randomised controlled stage 2b trial. Lancet Reg Health Eur 2024;39:100864. PubMed 38420108 · DOI
  37. DIPLOMA-2, monitorizarea activității. Bruna CL, Emmen AMLH, de Graaf N et al.. Activity and Physiological Stress Within 90 Days After Minimally Invasive and Open Pancreatoduodenectomy: A Predefined Analysis of the DIPLOMA-2 Randomized Clinical Trial. JAMA Surg 2026;161:682-689. PubMed 42160093 · DOI
  38. Cost implementare DPC robotică (Amsterdam). Menso JE, Francken MFG, de Graaf N et al.. Cost-analysis of Implementing Robot-assisted Versus Open Pancreatoduodenectomy. Ann Surg 2026;284:353-362. PubMed 39928538 · DOI
  39. DIPLOMA-2, cost-eficiență. Menso JE, Bruna CL, de Graaf N et al.. Cost-effectiveness Analysis of Robotic Versus Open Pancreatoduodenectomy (DIPLOMA-2): A Multicenter International Randomized Trial. Ann Surg 2026;284:920-927. PubMed 42606345 · DOI
  40. LEARNBOT. Jones LR, Zwart MJW, Nickel F et al.. Pan-European Training Program for Robotic Pancreatoduodenectomy (LEARNBOT): Prospective Multicenter Study on Feasibility and Outcome. Ann Surg 2026;284:993-1001. PubMed 42839322 · DOI
  41. Benchmark DPC. Sánchez-Velázquez P, Muller X, Malleo G et al.. Benchmarks in Pancreatic Surgery: A Novel Tool for Unbiased Outcome Comparisons. Ann Surg 2019;270:211-218. PubMed 30829701 · DOI
  42. ISGPS 2016. Bassi C, Marchegiani G, Dervenis C et al.. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;161:584-591. PubMed 28040257 · DOI
  43. Fistula Risk Score. Callery MP, Pratt WB, Kent TS et al.. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216:1-14. PubMed 23122535 · DOI
  44. a-FRS. Mungroop TH, van Rijssen LB, van Klaveren D et al.. Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation. Ann Surg 2019;269:937-943. PubMed 29240007 · DOI
  45. ua-FRS. Mungroop TH, Klompmaker S, Wellner UF et al.. Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation. Ann Surg 2021;273:334-340. PubMed 30829699 · DOI
  46. Catalogul FRS. Trudeau MT, Casciani F, Ecker BL et al.. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg 2022;275:e463-e472. PubMed 32541227 · DOI
  47. Botea, Bârcu et al. 2022. Botea F, Bârcu A, Kraft A et al.. Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?. Medicina (Kaunas) 2022;58. PubMed 36295582 · DOI
  48. Bârcu 2021, Klatskin. Bârcu A, Kraft A, Verdea C et al.. En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor. Chirurgia (Bucur) 2021;116:634-638. PubMed 34749860 · DOI
  49. Kraft, Bârcu et al. 2023. Kraft A, Bârcu A, Barzan D et al.. The Survival Benefit of Repetitive Ultrasound-Guided Liver Resections in the Absence of Chemotherapy for Multiple Colorectal Recurrent Liver Metastases. Chirurgia (Bucur) 2023;118:229-236. PubMed 37480349 · DOI
  50. Kraft, Bârcu et al. 2023, GIST. Kraft A, Moldovan C, Bârcu A et al.. Salvage Hepatectomy for Giant GIST Liver Metastases Unresponsive to Systemic Therapy-Case Report. Life (Basel) 2023;13. PubMed 37629538 · DOI
  51. Mitricof, Bârcu et al. 2023. Mitricof B, Kraft A, Anton F et al.. Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature. World J Clin Cases 2023;11:3837-3846. PubMed 37383130 · DOI
  52. Popescu & Câmpeanu 2009. Popescu I, Câmpeanu I. [Surgical anatomy of the liver and liver resection. Brisbane 2000 Terminology]. Chirurgia (Bucur) 2009;104:7-10. PubMed 19388562
  53. DIPLOMA-2x2 (protocol). de Graaf N, Bruna CL, Menso JE et al.. Robot-assisted versus open pancreatoduodenectomy for cancer in the pancreatic head (DIPLOMA-2x2): study protocol for an international multicentre patient- and assessor-blinded randomized controlled non-inferiority trial. Trials 2026;27. PubMed 42464359 · DOI
  54. Miami 2019. Asbun HJ, Moekotte AL, Vissers FL et al.. The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg 2020;271:1-14. PubMed 31567509 · DOI
  55. ORANGE II. Wong-Lun-Hing EM, van Dam RM, van Breukelen GJ et al.. Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study). Br J Surg 2017;104:525-535. PubMed 28138958 · DOI

Information for surgeons and for anyone interested in surgery; it does not replace clinical guidelines or the judgement of the team treating a patient.