Comparison of laparotomy, laparoscopy, and da Vinci in Whipple, hepatectomy, pancreatectomy, and gastrectomy

Abstract

Background:

This study aimed to evaluate whether advances in surgical imaging and technology improve clinical outcomes, including operative time, hospital stay, and intraoperative bleeding, across four major hepatopancreatobiliary (HPB) surgeries: the Whipple procedure, hepatectomy, pancreatectomy, and gastrectomy, comparing open laparotomy, laparoscopic, and robotic-assisted (da Vinci) approaches.

Material and Methods:

A retrospective observational cohort study was conducted using a prospectively maintained database from a university-affiliated minimally invasive surgery center. A total of 486 patients (269 males, 217 females; mean age 57.96 ± 15.71 years) who underwent HPB surgery between July 2015 and September 2019 were included. Surgical method selection was determined by surgeon preference, patient condition, and the chronological introduction of the da Vinci system. One-way analysis of variance was used to compare operative time, hospital stay, and blood loss among the three methods in each surgical category.

Results:

Significant differences were observed among surgical approaches. In gastrectomy, hospital stay [F(2,158) = 18.66, P < 0.001] and bleeding [F(2,158) = 16.25, P < 0.001] were significantly lower in laparoscopic and robotic groups. In pancreatectomy, operative time [F(2,80) = 3.48, P = 0.04] and bleeding [F(2,80) = 3.16, P = 0.05] showed significant variation, with longer duration in laparoscopy. In the Whipple procedure, only operative time differed [F(1,76) = 26.53, P < 0.001]. In hepatectomy, operative time [F(2,161) = 3.48, P = 0.03], hospital stay [F(2,161) = 11.53, P< 0.001], and bleeding [F(2,161) = 18.29, P < 0.001] were significantly improved in minimally invasive and robotic groups.

Conclusions:

Minimally invasive and robotic-assisted surgeries significantly reduced hospital stay and intraoperative bleeding compared with open laparotomy. Operative time varied across procedures, reflecting technical complexity and learning curves. These findings highlight the clinical benefits of image-guided and robotic-assisted techniques in complex abdominal surgery.

Introduction

During open surgery, also called laparotomy, after anesthetizing patients, surgeons make a single large incision over the affected part and examine the structures involved with their eyes and hands. In the past decades, with the development of endoscopes, minimally invasive surgery (MIS) has improved^[1], and surgeons can now make small skin incisions (5–10 mm) through which an endoscope can be inserted into the body to examine internal structures. The enlarged image of the affected part is synchronously displayed on a monitor. Using the monitor, surgeons can perform MIS.

HIGHLIGHTS

• This study analyzed 486 patients undergoing four major hepatopancreatobiliary (HPB) surgeries – Whipple procedure, hepatectomy, pancreatectomy, and gastrectomy – across three surgical methods (open, laparoscopic, robotic-assisted).

• It represents a retrospective observational cohort using a prospectively maintained 5-year institutional database (July 2015–September 2019).

• Minimally invasive and robotic-assisted surgeries significantly reduced hospital stay and intraoperative bleeding compared with open laparotomy (P < 0.001).

• Operative time varied by procedure type, particularly in pancreatectomy and Whipple operations, reflecting different learning curves and technical demands.

• This is the first comparative evidence demonstrating significant outcome differences among open, laparoscopic, and da Vinci robotic methods across four HPB operations within a single institutional framework.

Laparoscopic surgery originated from the technical development of endoscopes. Phillip Bozzini, a Frankfurt doctor, was the first to record the possibility of using endoscopy for diagnosis^[2]. In the mid-1800s, the prototype of the modern endoscope was used in the medical field. In 1853, Desormeaux, a French doctor, coined the word “endoscope” and invented the transurethral endoscope, which was used in visualizing the lumen of the urethra and bladder^[3]. In the late 1800s, Kussmaul, Nitze, and other doctors optimized the original endoscope model and used the improved model for other medical purposes. George Kelling, a German surgeon, pioneered the use of laparoscopy or endoscopy in abdominal examination in 1901, and he named the process “koelioscopie”^[4]. In the early 1930s, the non-diagnostic purpose of laparoscopy was first published and surgeons used laparoscopes to separate abdominal adhesions. In the 1960s and 1970s, laparoscopic examination became an important part of gynecology. Although there were great improvements in laparoscopic skills, it was not until 1986 that laparoscopic surgery was integrated with general surgery, along with the development of imaging systems and electronics for image magnification and projection.

To address the complexity and potential dilution of precision in analyzing surgical outcomes due to the varied procedures, this research focuses on a well-defined subset of surgical interventions where the control of experimental variables has been prioritized. This focused approach allows for a more precise attribution of outcomes specifically to the surgical method employed, thereby enhancing the clarity and relevance of the analysis.

In a systematic review published by Montalti et al^[5], a laparoscopic instrument with an ordinary endoscope produced a two-dimensional (2D) image with tremor amplification. Furthermore, rigid instruments limit the surgeon’s degree of motion^[6]. However, even if MIS and laparoscopic surgery have been widely accepted in the surgical field, they still have some limitations, such as posture discomfort and tremors^[7]. With the advanced technology of robotic assistants, the da Vinci surgical robotic platform was invented to enable small incisions, scarless surgeries, and faster recovery of patients^[8,9].

In 1998, adopting the technological concepts of MIS and remote procedures, intuitive surgery was the first human trial in Germany, France, and Mexico for surgeries, such as mitral valve repair, transthoracic mammary harvesting, cholecystectomy, and Nissen fundoplication^[10]. The da Vinci system was approved by the US Food and Drug Administration after 2 years and was introduced in the US health care market^[11]. A robotic surgical system was developed to overcome the limitations of laparoscopic surgery in terms of easy performance and comfort^[12]. Robotic surgery has also been shown to have satisfactory initial surgical outcomes that are comparable to those of the laparoscopic method^[7].

Imaging systems

Another advancement of the da Vinci systems over conventional laparoscopic surgery is that the visual imaging system plays an important role in many different aspects. For example, in Kim’s study^[6], the results indicated that three-dimensional (3D) robotic surgery is more helpful than 2D laparoscopic surgery in terms of preventing the surgeons from being distracted during surgery.

In conventional surgery, surgeons inspect target organs directly with their eyes, which forms a 3D visual perception, and they operate directly with their hands. However, if tissues or vessels are too small to be visualized with the naked eye, surgeons wear a loupe (Fig. 1), which magnifies the image by 5–10 times. Hence, surgeons can perform precise resection or suturing of small tissues or vessels. Previously, MIS commonly used 2D vision to support surgeons. A 2D imaging system (GIMMI®) consists of a high-resolution camera and a 10-mm diameter laparoscope. However, owing to the flat images, 2D vision lacks the perception of depth and spatial orientation^[13]. Therefore, indirect references, such as changes in shadows and textures, assist surgeons in performing surgery. Currently, 3D MIS is a medical term based on the application of 3D images to laparoscopy, endoscopes, and robotic-assisted surgery. This technique was first introduced into the military and film/movie industry about 20 years ago, and in the last 10 years, it is gradually being used in clinical medicine^[14].

Figure 1.

Images showing the differences in incision (A) and scars (B) for MIS and open surgery. MIS, minimally invasive surgery.

Due to system delay, poor resolution, and expensive equipment, 3D MIS was not mainstream in MIS before the 2000s. However, these problems were solved by the new technology of HD screens and advanced camera systems^[15]. 3D vision with high resolution and the 10-times magnified imaging effect are important characteristics of the da Vinci system. In addition, a pair of endoscope lenses is integrated into one 12-mm endoscope to obtain 3D stereoscopic vision in both eyes, and the perception of depth is obtained^[16]. In the new context, preclinical research has indicated that it is beneficial to use 3D techniques during simulated laparoscopic training, as it reduces operative time and the rate of mistakes^[13,17].

In 1987, Doctor John EA Wickham published a paper that mentioned MIS in the British Medical Journal. Since then, there have been many research papers on non-randomized trials, randomized controlled trials (RCTs), and meta-analyses comparing laparoscopic and open surgery, which have verified that minimally invasive laparoscopic surgery has obvious advantages^[18–20]. The wound with MIS produced is much smaller than that in conventional surgery; however, both have the same effective surgical outcomes. A comparison of the characteristics of wounds and postoperative scars between the two methods of surgery is presented in Fig. 1. In MIS procedures, medical instruments are inserted into the patient’s body via a trocar, and the surgeon manipulates these laparoscopic instruments to perform surgery outside patients’ bodies.

The particularly different characteristic between MIS and open surgery is that MIS only produces a few small wounds; on the contrary, open surgeries are associated with large wounds. In the past few decades, robotic surgical systems have been introduced and have brought a new era of MIS^[7]. These benefits have improved clinical outcomes and reduced the possibility of surgical complications^[21], such as blood loss and pain. Furthermore, patients’ wounds are getting smaller and more cosmetically appealing. All fields of surgery, such as orthopedics, gynecology, urology, and general surgery, have developed new method of operations because of MIS.

Hepatopancreatobiliary surgery)

MIS has been adopted in various fields, including hepatopancreatobiliary (HPB) surgery, due to the development of lens instruments, energy devices, and imaging systems. Additionally, MIS is viewed as a standardized surgical method, such as in laparoscopic cholecystectomy. Even if conventional surgery is more advantageous in some aspects with advanced surgical instruments and medical equipment, the curing effect of MIS is the same as that of conventional surgery. The applications of MIS in HPB surgery are diverse, ranging from laparoscopic cholecystectomy to resection of liver, pancreatic, and gastric cancer among others. In addition, MIS can be used for procedures on complex anatomical structures, for lymph node dissection, for vascular resection, and for organ reconstruction and transplantation.

There has been a great improvement in conventional surgery and the development of the da Vinci system in many aspects. The evolution of modern surgery from laparotomy, laparoscope, to da Vinci, with the development of the endoscope from human eyes, 2D, to HD 3D imaging systems, has explained the advantage and disadvantages separately. There was a lack of evidence to see the difference between these three surgeries. Therefore, the purpose of this study was to compare the outcomes of using laparotomy, laparoscopy, and the da Vinci system in Whipple, hepatectomy, pancreatectomy, and gastrectomy surgeries. This present study aimed to provide a systematic consequence based on examining the qualitative and quantitative data.

Materials and methods

Patients

This study was conducted with the support of a university-affiliated MIS center, which included a general surgery team experienced in open, laparoscopic, and robotic-assisted surgery. All surgeries were performed by the general surgery team of the same university hospital, including three attending surgeons from the MIS center who were proficient in all three surgical techniques. Less experienced surgeons participated under the supervision of senior attending surgeons to ensure procedural consistency and adherence to institutional standards. The study employed a retrospective observational cohort design utilizing a prospectively maintained institutional database covering a 5-year period from July 2015 to September 2019 at a university medical center. A total of 486 patients who underwent one of four major abdominal surgeries: Whipple procedure, hepatectomy, pancreatectomy, or gastrectomy, were included in the analysis. The cohort comprised 269 male patients (mean age = 58.39 ± 15.49 years) and 217 female patients (mean age = 57.48 ± 16.00 years), with an overall mean age of 57.96 ± 15.71 years. Patients were not randomized to surgical groups. Instead, assignment to the three surgical approaches – open laparotomy, 2D laparoscopic surgery, and robotic-assisted surgery using the da Vinci system – was determined by surgeon preference, patient clinical condition, financial support, and the chronological introduction of the da Vinci system at the hospital. The choice of surgical method was made based on the patient’s clinical condition, disease stage, and surgeon’s judgment, which may introduce an element of selection bias. As the robotic system was adopted in the later phase of the study period, patients treated thereafter were progressively included in the da Vinci group. Therefore, patient allocation reflected a time-sequential and convenience sampling process rather than randomization. The study was registered on ClinicalTrials.gov and has been reported in accordance with the STROCSS (Strengthening the Reporting of Cohort Studies in Surgery) criteria (Agha at al., 2025)^[22].

Da Vinci Xi robotic system

The Intuitive Surgical® da Vinci® Xi Endoscopic Instrument Control System (da Vinci Xi System) and Endoscopic Instruments (Intuitive Surgical, Sunnyvale, CA, USA) is the fourth generation of the da Vinci system and was launched in 2014. The da Vinci Xi system is designed to overcome the limitations of previous platforms and is considered an updated version. One of the characteristics of the da Vinci Xi system is use of the EndoWrist instruments, which provide surgeons with natural dexterity and free movement to enhance precision during MIS. Furthermore, the laparoscope has a brand-new design with high resolution, is a 3D, 8-mm digitalized scope, with autofocus, and can white balance, which produces better images^[23]. The scope can be placed on any robotic arm, and this gives surgeons a wider range of views. Improvements in the robotic arms also greatly reduce the rate of collisions between the robotic arms. The da Vinci Xi System is more user-friendly, simpler, and easier to dock compared to previous versions^[12].

Surgical procedure

Regardless of the surgical methods (laparotomy, laparoscopy, or da Vinci system), the first step after the patient enters the operating room is always anesthesia. After administering anesthesia, the following different operation procedures result in different viewing images. Here, we describe the differences in these three surgical methods using the key steps of visualization in each technique. Figure 2 shows the operation procedure.

Figure 2.

Procedure of the three different surgical methods.

During laparotomy, the surgeon opens the patient’s body directly and operates with the naked eye. One disadvantage of laparotomy is that large wounds require more time to recover. In 2D laparoscopy, a 2D screen shows an image that allows the surgeon to perform stereoscopic surgery. Although most surgical processes are similar between laparoscopy and robotic surgery, the imaging system has been greatly improved in robotic surgery. In surgery using the da Vinci system, an endoscope that acquires HD 3D images from the surgical site is used. Images are processed using a video processor in the vision cart and displayed on a 3D viewer and touchscreen. Advances in imaging techniques have also provided more precise vision for surgeons.

Variables

From laparotomy to robotic-assisted surgery, advanced technology, such as artificial intelligence and 3D techniques, has allowed surgeons to perform surgery precisely. Moreover, patients benefit from a small wound, shorter operative time, lower error rates, and reduced bleeding^[24]. This study aimed to determine if improvements in imaging translate into patients’ outcomes, in terms of operative time, hospital stay, and hemorrhage in operations, namely, the Whipple procedure, hepatectomy, pancreatectomy, and gastrectomy, using three surgical methods, namely laparotomy, laparoscopy, and the da Vinci system.

A variety of devices and techniques, including energy sources, vascular staplers, three-chip cameras, and robotic assistance, have allowed surgeons to perform complicated operations with greater confidence^[25]. In particular, the da Vinci robotic platform, with its stable surgical platform and articulated wrist robotic arms, provides superior control and precision during surgical procedures. Surgeons trained at the same da Vinci Center demonstrate consistent proficiency in handling the robotic arms, resulting in a more uniform surgical technique across different cases. Therefore, perioperative outcomes with better devices are believed to be more significant. In this study, data on operative time, hospital stay, and intraoperative bleeding among the three types of surgical methods across four HPB surgeries were collected for analysis. Operative time was defined as the total duration from the initial skin incision to wound closure. Intraoperative bleeding referred to the total volume of blood loss recorded during the operation. Hospital stay represented the total number of postoperative days from surgery to discharge, reflecting the patient’s recovery time and postoperative rehabilitation process.

Statistical analysis

Statistical analyses were performed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ±standard deviation. One-way analysis of variance (ANOVA) was used to compare differences among the three surgical methods for each of the four HPB surgeries. When significant differences were found (P < 0.05), Tukey’s HSD post hoc tests were conducted to identify pairwise group differences. To control for multiple comparisons, Bonferroni correction was applied where appropriate. All tests were two-tailed, and significance was defined as P < 0.05 after adjustment. Analyses focused on the relationships among surgical methods and three perioperative outcomes: operative time, hospital stay, and intraoperative bleeding.

Qualitative analysis

Laparoscopic MIS is currently one of the main surgical methods used in district hospitals and national medical centers in Taiwan. Each medical center has its own standards for surgical procedures and techniques. In this study, three medical doctors from a university-affiliated MIS center were interviewed through semi-structured qualitative interviews to provide expert insights comparing their experiences with the different surgical approaches.

Results

Qualitative comparison

To complement the quantitative results, a qualitative assessment was conducted through interviews with three board-certified general surgeons from the university’s MIS center. Each had over 10 years of experience performing open, laparoscopic, and robotic-assisted HPB surgeries. Participants were selected through purposeful sampling to represent surgeons proficient in at least two of the three surgical modalities. Interviews followed a semi-structured format with open-ended questions addressing operative efficiency, learning curves, and patient recovery outcomes. A researcher independent of the surgical team conducted all interviews, each lasting about 30–45 minutes, which were audio-recorded and transcribed verbatim. Data were analyzed using thematic content analysis, and two investigators independently coded the transcripts to ensure reliability. Divergent opinions were discussed until consensus was reached, while contrasting views were retained to reflect the range of expert perspectives. Overall, the surgeons agreed that minimally invasive and robotic-assisted surgery are safe, practical, and beneficial for reducing hospital stays and bleeding, though they noted that longer operative times and steep learning curves remain challenges during the early adoption phase. Table 1 shows more details on the comparison of the surgical methods.

Table 1.

Comparison of method in surgery

Items	Laparotomy	Laparoscopic surgery	da Vinci system
Image	Direct image no magnified	2D flat magnified image	3D magnified image (10-12 times)
Flexibility	Higher	Low	High
Touch sensation	Direct touch sensation	Slightly touch sensation	No touch sensation (3D-assisted)
Size of wound	Big wound	3–4 small wounds	3–4 small wounds
Bleeding	Higher bleeding	Lower bleeding	Lower bleeding
Operative time	Medium	Long	Medium
Tremor of Instruments	Low	High	No
Physical Consumption	Medium	High	Low
Recovery time	Long	Short	Short
Hospital stay	Long	Short	Short
Learning curve	Short	Long	Short
Cost	Low	Medium	High

Demographic analysis

From July 2015 to September 2019, 486 patients underwent HPB surgery in a university medical center, which included 269 men and 217 women. All patients were divided into four different surgery groups: gastrectomy (n = 161), pancreatectomy (n = 83), Whipple (n = 78), and hepatectomy (n = 164). Each group consisted of three different surgical methods, including laparotomy, 2D laparoscopic surgery, and the da Vinci system (Table 2).

Table 2.

Demographic analysis

	Laparotomy	Laparoscope	da Vinci	Total
Gastrectomy (n)	50	48	63	161
Male/female (n)	24/26	24/24	38/25	86/75
MAge ± SD	62.4 ± 14	45.69 ± 16	53.94 ± 18.7	54.1 ± 17.7
Pancreatectomy (n)	28	10	45	83
Male/female (n)	17/11	3/7	18/27	38/45
MAge ± SD	58.3 ± 13.9	44.4 ± 12.8	50.5 ± 16.4	52.4 ± 15.8
Whipple (n)	20	NA	58	78
Male/Female (n)	12/8	NA	35/23	47/31
MAge ± SD	66.2 ± 11.1	NA	66.2 ± 10.3	66.27 ± 10.4
Hepatectomy (n)	37	41	86	164
Male/Female (n)	22/15	21/20	55/31	98/66
MAge ± SD	62.1 ± 12.3	58.6 ± 17	61 ± 11.6	60.6 ± 13.3

NA, not applicable.

Perioperative outcomes

In this study, we used one-way ANOVA to analyze the operative time, hospital stay, and bleeding among the three types of surgical methods in four different HPB surgeries; please see Table 3 for more details.

Table 3.

Results of perioperative (P-value)

	Gastrectomy (n = 161)			Pancreatectomy (n = 83)			Whipple (n = 78)			Hepatectomy (n = 164)
	M (SD)	F	Sig p	M (SD)	F	Sig p	M (SD)	F	Sig p	M (SD)	F	Sig p
Operative time/min
Laparotomy	138.88(63.83)	2.32	.10	133.71(65.84)	3.48	.04*	236.85(86.76)	26.53	.03*	147.35(73.15)	3.48	.03*
Laparoscope	152.25(71.39)			198.20(81.41)						187.78(80.53)
da Vinci	165.21(58.39)			159.84(64.74)			371.12(103.82)			168.33(56.71)
Hospital stay/day
Laparotomy	28.46(20.28)	18.66	.00*	29.57(43.65)	2.54	.09	51.84(28.53)	1.47	.23	18.70(11.26)	11.53	.00*
Laparoscope	9.96(7.66)			18(17.35)						12.24(7.54)
da Vinci	14.49(16.18)			14.91(10.43)			41.76(32.07)			11.49(5.84)
Bleeding/ml
Laparotomy	255(377.65)	16.25	.00*	564.46(1095.21)	3.16	.04*	715.5(524.60)	1.14	.29	1224.32(1226.78)	18.29	.00*
Laparoscope	37.08(55.32)			206(318.29)						371.59(652.67)
da Vinci	51.67(63.99)			167.67(235.31)			564.05(550.31)			371.82(457.75)

^*P <0.05 was statistically significant

In gastrectomy, hospital stay [F(2,158) = 18.66, P < 0.001] and bleeding [F(2,158) = 16.25, P < 0.001] showed significant differences among surgical methods, while operative time showed no significance (P > 0.05). Post hoc Tukey analysis indicated that patients in the da Vinci group spent an average of 13.97 days less in hospital compared with the laparotomy group [95% CI (–21.36,−6.58), P < 0.001], and those in the laparoscopy group spent 18.50 days less [95% CI (–26.39,−10.62), P < 0.001]. Regarding blood loss, the da Vinci group lost 203.33 mL less blood [95% CI (–304.58,−102.09), P < 0.001)], and the laparoscopy group lost 217.92 mL less [95% CI (–325.93,−109.90), P < 0.001] than laparotomy.

In pancreatectomy, operative time [F(2,80) = 3.48, P = 0.04] and bleeding (F(2,80) = 3.16, P = 0.05) were significant, while hospital stay was not (P > 0.05). Tukey’s post hoc test showed that laparoscopic surgery required 64.49 minutes longer than open surgery [95% CI (1.83, 127.14), P = 0.04], though this difference did not remain significant after Bonferroni adjustment.

In the Whipple procedure, only operative time differed significantly (F(1,76) = 26.53, P < 0.001), with hospital stay and bleeding showing no significant difference (P > 0.05).

In hepatectomy, all three outcomes were significant: operative time [F(2,161) = 3.48, P = 0.03], hospital stay [F(2,161) = 11.53, P < 0.001], and bleeding [F(2,161) = 18.29, P < 0.001]. Post hoc comparisons revealed that patients in the da Vinci group stayed 7.21 days fewer in hospital [95% CI (–11.01,−3.42), P < 0.001] and those in the laparoscopy group stayed 6.46 days fewer [95% CI (–10.84,−2.08), P = 0.002] than laparotomy. Regarding blood loss, the da Vinci group lost 852.50 mL less blood [95% CI (–1219.43,−485.57), P < 0.001], and the laparoscopy group lost 852.74 mL less [95% CI (–1275.18,−430.30), P < 0.001]. Operative time was moderately longer in the laparoscopic group than in open surgery [+40.43 minutes, 95% CI (2.57, 78.28), P = 0.03].

Overall, Tukey’s HSD post hoc analyses, supported by Bonferroni-adjusted comparisons, consistently demonstrated that minimally invasive and robotic-assisted surgeries were associated with shorter hospital stays and less intraoperative bleeding compared with open laparotomy, while operative time varied according to procedure type and complexity. Post hoc comparisons between the laparoscopic and da Vinci groups revealed no significant difference in most procedures, indicating comparable performance between the two minimally invasive approaches across the analyzed outcomes.

Discussion

During gastrectomy, patients who underwent robotic-assisted surgery had a significantly shorter hospital stay and less intraoperative bleeding compared with those who underwent laparotomy, consistent with the findings reported by Huang et al^[26]. and Shen et al^[7]. In pancreatectomy, Whipple procedures, and hepatectomy, significant differences in operative time were observed. The operative time for laparotomy was shorter than that for robotic-assisted surgery, likely because open procedures typically involved multiple assistant surgeons, each responsible for specific intraoperative tasks, thereby improving overall efficiency. In contrast, the use of the da Vinci system requires additional time for equipment setup, docking, and console operation, contributing to a longer operative duration. Montalti et al^[5] similarly reported that robotic hepatectomy was associated with reduced blood loss but longer operative times compared with laparoscopy^[5,24]. Regarding hospital stay, significant differences were found in gastrectomy and hepatectomy, whereas no significant difference was observed in pancreatectomy and Whipple procedures. Pancreatic surgeries are inherently more complex and often associated with higher complication rates and prolonged postoperative recovery, as also noted by Sergio et al^[23] and Kim et al^[24]. These findings suggest that the benefits of robotic-assisted surgery may be procedure dependent, reflecting variations in surgical complexity and required perioperative management. In our institution, surgeons preferred to extend postoperative hospitalization for patients undergoing pancreatic surgery to ensure full recovery and minimize the risk of delayed complications, which may explain the absence of a statistically significant difference in hospital stay between the da Vinci and laparotomy approaches for these procedures.

Our study revealed that advancements in imaging technology have played a pivotal role in the evolution of surgery from open laparotomy, which is associated with larger incisions and greater postoperative pain, to minimally invasive and robotic-assisted approaches. The major advantage of these technological improvements lies in the ability to perform surgery through smaller incisions, resulting in better cosmetic outcomes, reduced pain, and faster postoperative recovery. Robotic-assisted surgery also offers enhanced hemodynamic stability and a shorter recovery period compared with open procedures. In contrast, laparoscopic surgery – while less invasive than laparotomy – has traditionally been limited by a two-dimensional imaging system and restricted instrument maneuverability, which can contribute to longer operative times and greater blood loss. Despite these limitations, laparoscopy remains the most widely practiced minimally invasive technique in Taiwan due to its accessibility and proven safety. The emergence of robotic MIS represents a natural progression from conventional laparoscopy. By replacing the 2D visual system with three-dimensional, high-definition imaging, robotic platforms enable greater depth perception and more precise tissue handling, thereby improving surgical dexterity and clinical outcomes. These findings are consistent with previous studies, which have demonstrated that the transition from 2D to 3D visualization significantly enhances spatial orientation, depth perception, and overall surgical precision^[6,13,25]. Furthermore, regarding surgical equipment, chemical materials have been shown to improve. For example, the 4Dfry is the newest product that can be used to prevent adhesion and reduce bleeding postoperatively. In future, surgical lenses and equipment will continue to evolve. Surgical lenses are also expected to maintain a high image resolution even though the lenses become smaller and more flexible. This kind of evolution will enable new surgical methods, such as natural orifice transluminal endoscopic surgery (NOTES), in which surgery is performed through a natural orifice, such as the mouth, stomach, rectum, vagina, anus, and urethra. There are two advantages of this method, namely the absence of surface wounds and reduction of pain. Furthermore, it is attractive to patients who are concerned about cosmetic outcomes. NOTES is an innovative method that is dependent on the advancement of the lens.

In 2017, indocyanine green (ICG) was introduced during hepatectomy and was shown to assist surgeons in precisely locating hepatic tumors. ICG emits green fluorescence under near-infrared (NIR) irradiation due to the deep tissue penetration of NIR light, enabling real-time intraoperative visualization of hepatic anatomy and tumor margins (Fig. 3). Originally developed as a photographic reagent during World War II, ICG was first applied in medicine in 1957 and has since been widely used in angiocardiography and hepatic function assessments. The integration of near-infrared fluorescence imaging, such as ICG, into robotic platforms further enhances intraoperative visualization and surgical precision, as described by DiMaio et al^[10]. A comparative evaluation between ICG-guided imaging and intraoperative ultrasound would be valuable in future studies to further determine the optimal modality for tumor localization during minimally invasive hepatectomy. These developments highlight how imaging technology continues to shape the evolution of hepatobiliary surgery toward greater precision and safety.

Figure 3.

ICG showing green light. ICG, indocyanine green.

This study has several limitations that should be acknowledged. Although data were collected prospectively, the analysis was conducted retrospectively within a single institution, which may limit the generalizability of the findings. The sample size in certain subgroups – particularly the robotic-assisted and laparoscopic Whipple procedures – was relatively small, precluding the use of multivariate regression or subgroup analysis for risk adjustment. To maintain model validity and avoid overfitting, a univariate one-way ANOVA approach was adopted for the primary comparisons. Additionally, potential confounders such as age, ASA classification, comorbidities, and tumor characteristics were not included in the current model, and certain disease-specific variables, including detailed tumor staging, prior surgical history, and biochemical profiles, were not fully available for all patients in the dataset. Future multicenter studies with larger and more comprehensive datasets are warranted to perform risk-adjusted multivariate analyses and better assess the influence of these variables on surgical outcomes.

Another limitation is the potential influence of surgeon experience on operative outcomes. Although all surgeries were performed by the same institutional surgical team under standardized protocols, and less experienced surgeons operated under senior supervision, differences in technical expertise and learning curves may still have introduced unmeasured confounding. Because surgeon identifiers were anonymized in the dataset, we were unable to statistically adjust for this factor using models such as generalized estimating equations or random-intercept generalized linear models. Future studies with identifiable surgeon-level data should consider hierarchical or experience-adjusted modeling to better isolate the independent effects of surgical technique from surgeon experience.

Another potential source of bias may stem from differences in hospital stay data, as Taiwan’s National Health Insurance provides universal coverage, while some patients with additional private insurance may extend hospitalization for comfort or observation beyond standard medical necessity. Future studies should therefore perform cross-analyses or stratified comparisons to account for these variations and minimize this potential confounding effect. Furthermore, while the present study primarily focused on short-term outcomes, such as operative time, hospital stay, and intraoperative bleeding, it may not fully capture the broader clinical and technological advantages of robotic surgery. The distinction between the general benefits of MIS and the unique advantages offered by robotic technology, including enhanced precision, improved dexterity, and reduced tissue trauma, remains to be clearly defined. Future investigations should therefore aim to isolate and quantify the specific value added by robotic systems in complex surgical procedures to better delineate their independent contribution beyond conventional MIS approaches.

Conclusions

This study demonstrated that robotic-assisted surgery was associated with a shorter hospital stay and less intraoperative bleeding in gastrectomy compared with open laparotomy, whereas operative times were generally longer for robotic procedures across pancreatectomy, Whipple, and hepatectomy due to system setup and docking requirements. These findings suggest that the advantages of robotic-assisted surgery are procedure-dependent and influenced by surgical complexity and perioperative management. Advances in imaging technology, including three-dimensional visualization and near-infrared fluorescence with ICG, have further enhanced surgical precision and safety. Although the retrospective, single-center design and limited subgroup sizes restrict generalizability, this study highlights the ongoing evolution of minimally invasive and robotic surgery toward improved precision and patient recovery. Future multicenter, risk-adjusted studies are warranted to clarify the independent benefits of robotic systems beyond those of conventional minimally invasive techniques.

Ethical approval

This study was approved by the Institutional Review Board of Chung Shan Medical University Hospital, and the issue number was CS1-20103.

Consent

All patients included in this retrospective study underwent robotic surgery for gastrectomy, liver resection, or pancreatectomy as part of routine clinical care during the study period. The research involved no sensitive topics and posed minimal risk, with no greater potential harm than that encountered in standard medical treatment. In accordance with ethical standards, the study was approved by the Institutional Review Board of the affiliated medical center (approval number: CS1- 20103). The waiver of prior informed consent was granted on the basis that it did not compromise the rights or welfare of the participants.

Sources of funding

All authors did not receive funding for the work reported in the manuscript.

Author contributions

Cheng-Ming Peng, contributions: designed research, conducted research, provided databases, and analyzed data. Ming-Hung Lin, contributions: designed research, conducted research, performed statistical analysis, and had primary responsibility for final content. Chin-Tui Lin, contributions: designed research, conducted research, provided essential materials, and analyzed data. Teng-Chieh Cheng, contributions: designed research, conducted research, and analyzed data. Ssu-Yu Yeh, contributions: designed research, conducted research, performed statistical analysis, and wrote paper. All authors have read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no conflicts of interests.

Research registration unique identifying number (UIN)

ClinicalTrials.gov Identifier: NCT07034495.

Guarantor

Cheng-Ming Peng and Ming-Hung Lin.

Provenance and peer review

This was not an invited paper.

Data availability statement

The data sharing is not applicable to this article.

Assistance with the study

None.

Presentation

None.