Comparison of outcomes of laparoscopic vs. robotic surgical resection of pancreatic neuroendocrine tumors: a systematic review and meta-analysis

Abstract

Introduction

Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms. Minimal access surgery has been the favoured approach for these tumors over the past decade. There is a lack of robust data comparing laparoscopic and robotic pancreatic surgery for PNETs and this has led to the lack of a global conclusion regarding which approach is superior. Thus, we conducted a systematic review and meta-analysis of the available data to compare outcomes following laparoscopic versus robotic pancreatic surgery for pancreatic neuroendocrine tumors.

Methods

Studies reporting outcomes of laparoscopic or robotic surgery for pancreatic neuroendocrine tumors were included. Inverse variance and Mantel-Haenszel statistical analysis methods were used for continuous and dichotomous data, respectively. All outcomes were quantitatively analyzed using the random effects model. The risk of bias was assessed using the ROBINS-1 tool.

Results

A total of 14 studies with 767 patients were included. The mean difference in the operating time was 21.08 min (95% CI: -4.38, 46.54, I² = 43%), favouring the laparoscopic group. The pooled odds ratio for the rate of formation of the pancreatic fistula was 0.88 (95% CI: 0.54, 1.45, I² = 0%), favouring the robotic group. Blood loss was higher in the laparoscopic group (MD = -89.72 ml, 95% CI:-143.37 to -36.06, I² = 93%). Other parameters, including re-exploration rate, length of hospital stay, R0 resection, rate of conversion, and spleen preservation, were similar in both groups.

Conclusion

The robotic approach might be preferable to the laparoscopic approach because of the lower rate of POPF and blood loss. Larger randomised controlled trials are required to ascertain these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-025-03662-3.

Introduction

Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms with a yearly incidence of one per 100,000 individuals [1]. The incidence of functioning pancreatic neuroendocrine tumors is low, and their capacity to produce symptoms is based on the production of various hormones. In the current era, research on pancreatic neuroendocrine tumors has advanced notably, and their treatment has progressed toward a more comprehensive and minimally invasive approach [2].

Surgical resection has been considered a reliable treatment for PNETs as it is associated with improved survival [3]. With the progress in technology, minimally invasive surgery is being increasingly used to ameliorate the surgical trauma and complications associated with open surgery. In 1996, the first laparoscopic distal pancreatectomy was performed by Cuschieri for chronic pancreatitis followed by Gagner, who in the same year, performed laparoscopic surgery for an islet cell tumor [4, 5]. With developments in the robotic surgical system, the first case of robotic distal pancreatectomy (RDP) was reported by Melvin et al. in 2002, marking the dawn of a new era in minimally invasive pancreatic surgery [6]. Robotic surgery with its advantages of a high-definition, three-dimensional vision, along with seven degrees of freedom and better ergonomics has allowed surgeons to overcome certain difficulties associated with laparoscopy.

Pancreatic surgery has conventionally been known to be fraught with high rates of morbidity, predominantly in the form of post-operative pancreatic fistula. It is one of the main determinants that predict a patient’s post-operative course thus making it an important outcome of interest.

Alfieri et al. compared short and long-term outcomes after robot-assisted versus laparoscopic distal pancreatectomy for PNETs and showed that the laparoscopic procedure had a significantly lower spleen preservation rate and higher blood loss [7]. Another comparative study by Zhang et al. showed that patients who underwent robotic surgery had significantly higher spleen preservation rates, reduced blood loss, and better oncological outcomes with a higher lymph node harvest [8].

However, there is a lack of robust data comparing laparoscopic and robotic pancreatic surgery for pancreatic neuroendocrine tumors leading to the lack of a global conclusion. Thus, we conducted a systematic review and meta-analysis of the available data to compare outcomes following laparoscopic versus robotic pancreatic surgery for pancreatic neuroendocrine tumors.

Methods

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines [9]. The review was registered prospectively in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021264562).

Cohort studies and randomized controlled trials reporting outcomes of laparoscopic and robotic pancreatic surgery for pancreatic neuroendocrine tumors were included and case series of the same beyond the year 2000 and with a sample size of more than 10 were included.

Case reports, narrative reviews, expert opinions, studies with no retrievable texts, full English translation, and studies with only abstracts available, were excluded.

Study selection and data extraction

The literature search was done till December 2023 in electronic databases like Medline (PubMed), Ovid (Embase), Scopus, Web of Science, and Cochrane Central Registry of Trials (CENTRAL). The reference lists of all included studies and relevant systematic reviews for additional references were reviewed by two independent observers (DS, OP).

The pair of reviewers (DS, OP) independently screened titles and abstracts and duplicates were removed. The full texts of potentially eligible studies were reviewed to determine the final eligible studies. Disagreements were resolved by discussion with a third reviewer (VKB).

A standardized data extraction form was developed in Microsoft Excel by a reviewer DS. Data extraction was conducted by DS and verified by OP. The form included the first author, publication year, country, population, interventions, and outcomes, such as operating time and postoperative pancreatic fistula, blood loss, re-exploration rate, spleen preservation rate, length of hospital stay, rate of conversion, R0 resection percentage, and mortality. If necessary, DS reached out to study authors for additional information.

Search strategy

The search protocol was based on four search strings: Laparoscopic, Robotic, pancreatic neuroendocrine tumors, and PNETs. The categories were combined in the literature search using the Boolean operator “AND.” Within each category, MeSH terms and text words were combined using the boolean operator “OR.” Search strings for MEDLINE, Embase, Scopus, and Cochrane CENTRAL were used in similar words and strategy.

Final PubMed search strings were: (((“pancreatic neuroendocrine tumors“[All Fields]) OR (PNET)) AND (“laparoscopic“[All Fields]) AND (“robotic“[All Fields])), ((((((“pancreatic neuroendocrine tumors“[All Fields]) OR (PNET)) OR (neuroendocrine tumor)) OR (neuroendocrine tumors)))))) AND ((“laparoscopy“[All Fields]) OR (laparoscopic)) AND (“robotic“[All Fields]) & ((((pancreatic neuroendocrine OR PNET)) OR (laparoscopic)) AND (laparoscopy)) AND (robotic).

Data synthesis and analysis

The primary outcomes were the operating time and postoperative pancreatic fistula (POPF). The definition of POPF is in accordance with the ISGPS definition and grading [10]. The secondary outcomes included blood loss, re-exploration rate, spleen preservation rate, length of hospital stay, rate of conversion, R0 resection percentage, and mortality.

Pooled odds ratio (OR) and 95% confidence intervals (95% CI) were used for dichotomous outcomes such as operative time, blood loss, length of hospital stay, and mean difference (MD), and 95% CI were used for continuous outcomes such as postoperative pancreatic fistula, Re-exploration R0 resection, rate of conversion, spleen preservation, and mortality. For dichotomous data, the Mantel-Haenszel statistical analysis method was used, whereas the inverse variance statistical analysis approach was used for continuous data. Random-effects models to pool study data were used. statistical analyses were carried out using Review Manager version 5.4 [11]. Weighted means were calculated for the non-comparative studies.

Assessment of statistical heterogeneity

The heterogeneity in the meta-analyses was assessed by visual inspection of the Forest plot and by the I² statistic.

Risk of bias assessment

Using the “Risk of Bias in Non‑randomized Studies of Interventions (ROBINS‑I)” assessment tool [12], two independent researchers DS and MP determined any potential bias in the included non-randomized trials, and any disagreements were settled by discussing with VKB.

Evidence summary

The evidence was summarized both narratively and in GRADE evidence profiles. Four authors (DS, BY, MP, PK) assessed evidence quality using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. Evidence strength was categorized as high-quality (⊕⊕⊕⊕), moderate-quality (⊕⊕⊕⊖), low-quality (⊕⊕⊖⊖), or very low-quality (⊕⊖⊖⊖). Consensus resolved any discrepancies.

Funding

There was no funding for this study.

Results

The total number of titles obtained using the search terms in all the databases mentioned was 9758. They were screened independently by two reviewers (DS, OP) and duplicates were removed. The total number of titles after removal of duplicates was 9728 out of which 142 abstracts were selected for review. Of the selected abstracts, 23 full-text articles were assessed for their eligibility. The final number of studies included in the analysis was 14 (Fig. 1) [7, 8, 13–24].

Fig. 1.

PRISMA flowchart

There were three non-randomized comparative studies, eight retrospective cohort studies, and three retrospective case series. A total of 767 patients were included in this study. The sample size of the three comparative studies was 276 (35.9%). The weighted mean age of the laparoscopic group was 44.5 years (range, 20–95 years) and the robotic group was 28.4 years (range, 25–77 years). The mean tumor size was 23.4 mm (range, 2–130 mm) in the laparoscopic group and 16.3 mm (range, 3–40 mm) in the robotic group.

Risk of bias assessment

The risk of bias assessment for individual studies is shown in Fig. 2. All studies showed a low risk of bias in all aspects except for the bias due to missing data, and confounding which was unclear. The overall certainty of evidence for all the outcomes is shown in the supplementary table.

Fig. 2.

“Risk of Bias in Non‑randomized Studies—of Interventions. (ROBINS‑I)” assessment tool

Primary outcomes

Operating time

Three studies with 276 patients in both groups showed no significant difference in operating time between the two groups (MD = 21.08 min, 95% CI: -4.38, 46.54, low level of evidence), with moderate heterogeneity between the studies (I² = 43%) [7, 8, 22]. The weighted mean of 11 studies was 253.88 min (range, 133–417.4 min) in the laparoscopic group and 188.20 min (range, 117–270 min) in the robotic group [13–21, 23, 24]. (Fig. 3(a), Tables 1, 2, 3 and 4)

Fig. 3.

Forest plot showing analysis of (a): Operating time. (b): Incidence of Postoperative pancreatic fistula. (c): Intraoperative blood loss

Table 1.

Preoperative parameters

Year	Author	n=	Surgery performed		N	Male	Female	Age (Years)	SD/ Range
2016	Nell S [22]	21		Lap	14	7	7	35	8.8
				Robotic	7	4	3	30	11
2017	Zhang J [8]	74		Lap	31	12	19	48.7	12.3
				Robotic	43	20	23	47.9	10.5
2019	Alfieri S [25]	181		Lap	85	43	42
				Robotic	96	46	50
2015	Xourafas D [23]	73		Lap	73	41	32	61	20–95
2019	Di Benedetto [13]	12		Rob	12	6	6	53.8	25–77
2016	Tian F [14]	60		Rob	60	21	39	45.2	13.2
2016	Shi Y [15]	26		Rob	26	11	15	50.1	14.1
2017	Cienfuegos F [16]	36		Lap	36	17	23	55.1	12.1
2019	Kim H [17]	58		Lap	58	18	40	49.5	12
2008	Fernández-Cruz [18]	49		Lap	49	6	43	58.8	22–83
2018	Han SH [24]	42		Lap	42	21	21	53	30–75
2013	Haugvik SP [19]	65		Lap	65	31	34	59	21–87
2011	Hu M [20]	43		Lap	43	19	24	42.4	14.5
2011	Zhao YP [21]	27		Lap	27	9	18	44.7	18.6

Table 2.

Primary outcomes

Author	Group	Tumor size (mm)	SD/Range	Operating time (min)	SD/Range	POPF	A	B	C
Nell S	Lap	17	5–17	268		9	4	4	1
	Robotic	25	19–40	185		4	1	3	0
Zhang J	Lap	16	12–22	133.4	41.8	12	7	4	1
	Robotic	16	13–25	139.3	56.9	11	7	4	0
Alfieri S	Lap			233.7	65.6	34	17	15	2
	Robotic			270.2	90.2	40	20	17	3
Xourafas D	Lap	22	2-130	352		16	12	4	0
Di Benedetto	Robotic	11	3–15	203.17		3	2	1	0
Tian F	Robotic	13.7	3.4	117		6	0	6	0
Shi Y	Robotic	23	12	124.6	50.9	12	5	7	0
Cienfuegos F	Lap	20.5	13	287.8	99.1	13
Kim H	Lap	26	13	417.4	102.7	24	21	3	0
Fernández-Cruz	Lap	47	25–110			10	6	3	1
Han SH	Lap	13	6–52	168.5		29	25	4
Haugvik SP	Lap	22	5–95	175		14	1	13	0
Hu M	Lap			210.5	56.6	9	2	4	3
Zhao YP	Lap	15	5	178.5	68.3	11

Table 3.

Secondary outcomes

Author	Group	Blood loss (ml)	Re-exploration	Spleen preservation	LOHS (days)	Conversion	R0 resection
Nell S	Lap	100 (0-3500)	0		7 (3–41)	6	6
	Robotic	50 (50–400)	0	7	7 (5–12)	0	6
Zhang J	Lap	200	1	1	14.4 (7.2)	0	31
	Robotic	50	0	0	12.8 (6.8)	0	43
Alfieri S	Lap	239.7 (112)	4	38	10 (7.4)	12	84
	Robotic	162.5 (98)	6	64	11 (8.8)	9	96
Xourafas D	Lap		6		5 (3–18)	11	71
Di Benedetto	Robotic	38.3 (20–110)	0		3.9	0
Tian F	Robotic	32.5 (10-1000)	0		12 (6–36)	3	60
Shi Y	Robotic	76 (85.4)	0		22.6 (15.6)	0
Cienfuegos F	Lap		3	21	6 (0.9)	0	36
Kim H	Lap	433.2 (394)	1		12.6 (6.1)		55
Fernández-Cruz	Lap		1	37	6.3 (5–14)		49
Han SH	Lap	175	0		7 (4–18)		40
Haugvik SP	Lap	300 (5-2700)	5		7 (2–27)	4	39
Hu M	Lap	132.5 (155.7)	2		9.1 (5.6)
Zhao YP	Lap	124.8 (133.9)	0		15.1 (7.8)	19

Table 4.

Weighted mean of parameters

Group	Age (years)	Tumor size (mm)	Operative time (min)	POPF (total) (Grade)			Blood loss (ml)	Re-exploration	Spleen preservation	LOHS (days)	Conversion	R0 Resection	Mortality
				A	B	C
Lap	44.51	23.4	253.88	34.6%			190.4	4.39%	48.25%	10.49	15.7%	90.7%	1.7%
				60.5%	34.3%	5%
Robotic	28.4	16.31	188.20	31.1%			92.15	2.45%	50.6%	12.33	4.9%	99.5%	0.4%
				46%	50%	3.9%

Post-operative pancreatic fistula

Among the comparative studies, the POPF rate for robotic group was 55/140 (39.2%) as compared to 55/130 (42.3%) in laparoscopic group. The forest plot favoured the robotic group with an odds ratio of 0.88 and a heterogeneity of 0% (OR = 0.88, 95% CI: 0.54, 1.45, low level of evidence). On comparison of weighted percentages of 14 studies, the rate of POPF was almost equal in both groups (34.6% and 31.1% respectively for the laparoscopic and robotic groups). The percentages of grades A, B, and C in the laparoscopic group were 60.5%, 34.3%, and 5%, and the robotic group was 46%, 50%, and 3.9% respectively. (Fig. 3b), Table 4)

Secondary outcomes

Blood loss

Three studies with 276 patients in both groups showed a significantly lower incidence of blood loss in the robotic group than in the laparoscopic group (MD = -89.72 ml, 95% CI:-143.37 to -36.06, moderate level of evidence), with considerable heterogeneity between the studies (I² = 93%). Overall, 12 studies reported data on blood loss. The weighted mean was 190.4 ml and 92.1 ml in the laparoscopic and robotic groups respectively. (Fig. 3(c), Table 4)

Re-exploration

There was no significant difference in re-exploration rates between the two groups among the three studies (OR = 1.06, 95% CI: 0.32, 3.53, low level of evidence), with no heterogeneity between studies (I² = 0%). All the 14 studies reported data on re-exploration. The weighted percentage of re-exploration was 4.39% and 2.45% in the laparoscopic and robotic groups. (Fig. 4(a), Table 4)

Fig. 4.

Forest plot showing analysis of (a): Re-exploration rates. (b): Length of hospital stay. (c): R0 resection

Length of hospital stay

Three studies with 276 patients in both groups showed no significant difference in the length of hospital stay between the two groups (MD = 0.10 days, 95% CI: -1.80 to 1.99, low level of evidence) with no heterogeneity between the studies (I² = 0%). The weighted mean length of hospital stay from 14 studies was 10.4 days in the laparoscopic group and 12.3 days in the robotic group. (Fig. 4(b), Table 4)

R0 resection

There was no significant difference in R0 resection rates between the two groups among the three studies (OR = 5.94, 95% CI: 0.88, 39.93, low level of evidence), with no heterogeneity between studies (I² = 0%). Overall, ten studies reported data on R0 resection. The weighted percentage of R0 resection was 90.7% and 99.5% in the laparoscopic and robotic groups respectively. (Fig. 4(c), Table 4)

Rate of conversion

There was no significant difference in the conversion rate between the two groups among the three studies (OR = 0.40, 95% CI: 0.08–2.09, low level of evidence), with moderate heterogeneity between studies (I² = 35%). The weighted percentage of the rate of conversion from 10 studies reporting the data was 15.7% and 4.9% in the laparoscopic and robotic groups respectively. (Fig. 5(a), Table 4)

Fig. 5.

Forest plot showing analysis of (a): Rate of conversion.(b): Spleen preservation rates

Spleen preservation

There was no significant difference in spleen preservation rates between the two groups in the two studies (OR = 1.32, 95% CI: 0.17–10.24, very low level of evidence), with moderate heterogeneity between studies (I² = 50%). The weighted percentage of spleen preservation in four studies was 48.25% and 50.6% in the laparoscopic and robotic groups, respectively. (Fig. 5(b), Table 4)

Mortality

There was no mortality in either of the comparative studies. Eight studies reported data on mortality, and the weighted percentage from these studies were 1.7% and 0.4% in the laparoscopic and robotic groups, respectively. (Table 4)

Discussion

Several minimally invasive techniques for the management of PNETs have been developed in an attempt to reduce morbidity and improve the outcomes of pancreatic surgery. Owing to the location of the pancreas, laparoscopy has several limitations owing to restricted mobility and two-dimensional visualization. With the introduction of robotics in surgery, recent literature has shown good results with robotic surgery for pancreatic neuroendocrine tumors.

The primary outcomes of this study were the operative time and incidence of POPF following laparoscopic versus robotic resection of PNETs. These results suggest that the rate of POPF was similar among the three comparative studies. However, the incidence of POPF was lower in the robotic group. The rate and grade of pancreatic fistula were higher in the laparoscopic group in a study by Nell et al. The number of patients operated on by the laparoscopic approach was double that of those operated on by the robotic technique, which might have led to this result. Similarly, in a study by Zhang et al., the rate and grade of fistula formation were higher in the laparoscopic group. In a study by Alfieri et al., the rate of POPF was slightly higher (41.7% vs. 40%) in the robotic group. Considering the details of the three comparative studies, there is no evidence to suggest the superiority of the robotic over the laparoscopic approach.

The slightly higher incidence of POPF in the laparoscopic group obtained in this meta-analysis arose mainly from the difference in the POPF rates in the study by Nell et al. Other factors include the technique of closure of the pancreatic stump, which needs to be accounted for when comparing the rate of POPF in laparoscopic and robotic approaches. Patients operated upon by the robotic technique are likely to undergo stump closure by stapler along with sutures, which might be a plausible explanation for the results.

These are all small case series or comparative studies, and there is limited literature comparing laparoscopic and robotic surgery for pancreatic neuroendocrine tumors.

The other primary outcome of this study was the operating time. Three comparative studies were analyzed, of which two favored the laparoscopic group. However, these results were not statistically significant [7, 8]. An important consideration when comparing the operating times is the inclusion or exclusion of the docking time. The study by Alfieri et al. separately reported the docking time, which was not mentioned in the study by Zhang et al. The inclusion of docking time in the operating time might be responsible for the longer operating time in the robotic group. In contrast, a third comparative study by Nell et al. reported a shorter operating time in the robotic group. However, in their study, the percentage of enucleations (36% vs. 29%) was higher in the laparoscopic group, which may explain the results.

With regards to the extent of resection, the robotic approach seemed to achieve a higher rate of R0 resection. A total of 145/146 and 121/130 patients underwent R0 resection in the robotic and laparoscopic groups, respectively. The p value was approaching significance with an odds ratio of 5.94. Therefore, it can be inferred that the robotic approach might lead to a higher R0 resection rate. The majority of the long-term data compared laparoscopic and open approaches, and most of those studies were non-randomized with a selection bias towards the inclusion of smaller tumors in the laparoscopic group. It might be extrapolated that a better R0 resection rate might ultimately lead to higher overall survival. Long-term randomized studies are required to shed light on this hypothesis.

Blood loss was significantly lower in the robotic group, with a mean difference of 89 ml. The mean weighted blood loss was also lower in the robotic group (92 mL vs. 190 ml). Better 3D visualization, dexterity, and choice of smaller tumors for the robotic approach might be plausible reasons. All patients who underwent robotic surgery in the non-comparative studies underwent enucleation rather than resection, which could explain the lower blood loss in the robotic group. Among the comparative studies, two reported that patients underwent distal pancreatectomy. The third study by Nell et al. did not report on the type of procedure. The study by Kim et al. reported a mean blood loss of approximately 400 ml in 58 patients which skewed the weighted average blood loss towards a higher side in the laparoscopic group.

The rate of spleen preservation was reported in two comparative studies and was found to be higher in the robotic group, with an odds ratio of 1.32. The weighted percentage also favoured the robotic group, although the difference was small (50.6% vs. 48.25%, respectively). There are several small vessels connecting the pancreatic body and tail, and the splenic artery and vein. The vascular walls are easily ruptured during dissection, making safe separation of the pancreatic body and tail from splenic vessels a key point of spleen preserving surgery. Robot-assisted systems can effectively improve the dissection of splenic vessels and creation of the retro-pancreatic tunnel, thus improving the safety of surgery and rate of spleen preservation. None of the non-comparative studies commented upon rates of spleen preservation in the robotic group. Furthermore, only two non-comparative studies reported the rate of spleen preservation (68.2%) in the laparoscopic group.

The robotic approach favoured the rate of conversion with an odds ratio of 0.4 in the two comparative studies. The weighted percentage conversion was also higher in the laparoscopic group. The study by Alfieri et al. reports that the authors were adequately experienced in the robotic approach which resulted in low conversion rates in their study. Other comparative studies have not commented on the experience of surgeons in using laparoscopic and robotic approaches.

The rates of re-exploration were similar in the comparative studies, with an odds ratio of 1.04. The large comparative study by Alfieri et al. reported a lower re-exploration rate in the laparoscopic group (6.7% vs. 4.3%). However, the weighted percentage favoured the robotic group over the laparoscopic group (4.4% vs. 2.5%, respectively). Inclusion of more patients undergoing enucleation rather than resection and a smaller mean tumor size in the robotic arm might be a possible reason for the results.

With regards to mortality, laparoscopic group was found to have a marginally higher mortality (1.7% vs. 0.4%) on comparison of the overall percentage. This might be due to a selection bias towards a better patient profile in the robotic group. However, a lower overall rate of POPF, lower blood loss, higher rate of spleen preservation, higher R0 resection, and lower conversion rate in the robotic group would play a role in achieving lower mortality than the laparoscopic approach.

This is the first metanalysis to selectively compare the role of laparoscopic versus robotic approach for PNETs. Patients treated with newer surgical techniques may be healthier than those undergoing conventional treatments. This selection bias is likely because none of the included studies were randomised and all the studies were retrospective. Nevertheless, it should be noted that PNETs are rare and all patients with PNETs do not satisfy the criteria for surgery, thus making it difficult to carry out prospective randomised studies. The meta-analysis had a component of heterogeneity because of the inclusion of various surgical procedures under one heading, that is laparoscopic or robotic. The experience of the surgeon and cost of treatment, which are important practical considerations, could not be studied. Randomised studies with a larger sample size, although difficult to conduct are needed to strengthen the findings of this study.

In conclusion, robotic approach for pancreatic neuroendocrine tumors might be beneficial over laparoscopic approach in terms of rates of post-operative pancreatic fistula, blood loss, rate of conversion, R0 resection and spleen preservation in appropriately chosen patients. However, large multicentre comparative studies or randomised trials are required to substantiate the results. Long term follow-up comparing laparoscopic and robotic approach is required to comment on the oncological safety of the procedures. The reporting of outcomes of different surgical approaches such as enucleation and excision should be separately reported. The operating time in the robotic group should not include the docking time, which should be separately reported. Finally, surgeon experience, ergonomics and cost are important factors in any treatment approach and should be analysed in future studies.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

DS, VS, BY, MP wrote the main manuscript. The concept for the study was given by VKB. DS, OP performed the literature search and disagreements were resolved by VKB. The statistical analysis was done by DS, MP, BY, VS, PK. DS, AK, BY and MP prepared the figures. DS, VS and SR prepared the tables. All authors reviewed the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.