involvement by pancreatic tumors preoperatively and esti­mate the suitability of a patient for a robotic procedure. Vascular resection and reconstruction is well possible during robotic PD, however, it has to be planned and requires an adequate level of experience and technical kills when attempted. Otherwise, conversion to an open procedure— also in an emergency setting—is inevitable. This also implies that every surgeon doing robotic PD has to be trained not only in this procedure but also in open PD to be able to con­vert and x any occurring problem by an open approach if required—a merely robotic training seems to be inadequate in such a setting, especially as during the learning curve of robotic PD, an increased morbidity caused by intraoperative challenges may occur and high conversion rates are possible. Regarding the implementation of robotic PD, some precon­ditions have to be respected. Firstly, a center needs to have a level of experience in open pancreatic surgery and handling the potential complications; secondly, a certain case load has to be guaranteed—although there is no clear consensus on the minimal number of annal procedures, it seems to be rea­sonable to have a volume of at least 50 PDs per year to select proper patients for robotic PD and to surpass the learning curve for this procedure in a reasonable time frame. Thirdly, an environment of experienced open—an ideally—laparo­scopic surgeons has to be present, who are able and willing to go through training (including simulator skills, tissue training, visiting experienced centers), on-site proctoring and teaching of robotic PD. Presumed these preconditions are fullled, a patient selection is absolutely mandatory to start a robotic PD program. This implies to select clearly resectable cases of any type of pancreatic tumors to start and assure quality monitoring, which can be realized within a prospective database or a clinical study setting. Especially with regard to resectability of any pancreatic pathology, a certain selection bias is inherent during the learning curve of robotic PD.As it is common knowledge that during PD easy resection (small—potentially benign or borderline lesions, no duct dilation) is usually associated with rather difcult reconstruction (small pancreatic/bile duct, soft pancreatic remnant tissue), this may initially lead to an increase of post­operative morbidity, underlining the importance of compli­cation management to avoid any failure to rescue and endanger patients undergoing robotic PD.Furthermore, the standardization of all operative steps of PD is not only pos­sible but also helpful to achieve good outcomes. Giulianotti et al. published a 17-step procedure line for robotic PD including all key points of resection and reconstruction [11]. Although this is only a guide to perform the procedure and every patient may require individual adoption, a certain stan­dardization is certainly helpful and dened steps of the oper­ation can be standardized very well, i.e. positioning of the patient, trocar placement and positioning of the instruments on the respective arms of the robot [12]. A basic consideration

A denitive evaluation especially regarding long-term oncological outcomes is not possible from these data. A recent systematic review [19] includes 11 non-randomized studies comparing robotic and open PD. The number of robotic procedures in the underlying studies accounts to overall n=514 robotic PD vs. n=1263 open PD.The results show signicant differences in operation time (robotically +1.5h) and blood loss (robotically −200mL) with similar transfusion rate. In the subgroup of oncological patients, robotic PD showed a lower rate of R1 resections with a simi­lar number of retrieved lymph nodes. The data favor robotic

Long-term oncological outcome as the potentially most important variable for pancreatic cancer surgery has recently been investigated in an analysis of the US National Cancer Database [23]. Stage I–III pancreatic cancer patients who underwent either robotic PD (n = 626) or open PD (n=17.205) showed no relevant differences in baseline data regarding tumor characteristics. In the short-term outcomes, robotic PD was superior with regard to lymph node yield whereas R0 resection status was similar in both groups. Robotic PD resulted in a shorter hospital stay (−1 day) at similar readmission and 90-day mortality rates (9% vs. 8% readmission and 4% vs. 6% mortality, respectively. Median overall survival was 22.0months (robotic PD) vs. 21.8months (open PD) with 1-, 3- and 5-year survival rates of 74% vs. 73%, 33% vs. 31% and 19% vs. 19%, respectively. Based on such data, there should not be a general restrictive attitude towards robotic PD in malignant indications, even if results have to be considered with caution to the retrospective nature of this registry study.