研究背景：随着微创技术的发展，微创手术在胰体尾切除术中已成为主流方式。机器人手术因其三维可视化、震颤过滤、运动缩放和更好的人体工程学，已成为微创胰腺手术中一种应用前景良好的手术方法。目前已有研究探讨了机器人辅助胰体尾切除术（robotic distal pancreatectomy, RDP）相比于腹腔镜胰体尾切除术 (laparoscopic distal pancreatectomy，LDP)在围手术期安全性和可行性方面的优势，但各个结论不尽相同。本研究拟进一步综合比较RDP和LDP的围手术期结局指标，分析RDP手术的优势。与此同时，随着机器人系统在胰体尾切除术应用的逐渐增多，有必要探索RDP手术难度的术前影响因素并建立预测模型，为初学外科医生渡过RDP学习曲线提供指导并确保手术的安全性。

研究方法：1.首先系统检索PubMed、Embase和Cochrane Library数据库中收录的RDP和LDP比较的文献，检索截止至2022年6月。采用固定或随机效应模型进行两者围术期结局指标比较的荟萃分析。并利用敏感性分析探究异质性可能来源以及剪补法评估发表偏倚对结局的影响。2.随后回顾性分析2016年1月至2021年10月在北京协和医院行RDP手术的病人相关资料。利用多因素回归分析RDP手术难度的相关术前因素,并构建预测手术难度的列线图模型。

研究结果：1. 荟萃分析研究结果显示在良性及低度恶性计划保脾手术中，RDP组保脾率（OR 3.52, P <0.0001）及Kimura保脾率（OR 1.93，P <0.0001）显著高于LDP组。RDP组中转开腹率（OR 0.41, P <0.00001）、术后住院时间(WMD -0.57, P =0.002)显著低于LDP组，但住院总费用及手术费用更高。RDP组术后30天死亡率显著低于LDP组（0.1% vs. 1.0%，P =0.03），余术后并发症方面未见明显差异。2.男性 [OR (95%CI): 3.21(1.42-7.27), P =0.005]，BMI  [OR (95% CI): 1.13(1.01-1.27), P = 0.029], 肿瘤位于胰颈部 [OR (95%CI): 3.89(1.39-10.87), P = 0.010], 胰腺切割线位置位于胰颈部[OR (95%CI): 3.05(1.09-8.57), P = 0.034]和 脾动脉分型B型 [OR (95%CI): 3.21(1.06-9.74), P = 0.039]是RDP手术难度的术前危险因素。基于上述因素绘制了预测模型的列线图，该列线图表现出良好的区分度、校准度和临床有效性。

研究结论：1. RDP手术围术期结局优于LDP手术，技术上安全可行。高质量前瞻性随机对照研究有待进一步证实RDP手术的优势。2.男性、BMI，肿瘤位于胰颈部，胰腺切割线位于胰颈部和脾动脉分型B型与RDP手术难度呈正相关。基于logistic回归构建的列线图可帮助外科医生挑选合适的病人度过学习曲线，以增加手术安全性。

Background: With the development of minimally invasive techniques, minimally invasive surgery has become the mainstream method in the DP. Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP for perioperative outcomes. Meanwhile, as the use of robotic systems in distal pancreatectomy gradually increases, it is necessary to explore the preoperative factors of RDP surgical difficulty and establish a prediction model to provide guidance for surgeons lacking experience to surpass the RDP learning curve and ensure the safety of the surgery.

Methods: Firstly, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed by June 2022. Fix or random-effects models were used for the meta-analysis of perioperative outcomes. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Then, a retrospective study was conducted with patients who underwent RDP in Peking Union Medical College Hospital. Multivariate logistic regression was used to identify the preoperative factors of surgical difficulty and then a nomogram model to predict surgical difficulty was constructed.

Results: 1.RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52, p<0.0001) and Kimura method (OR 1.93, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, p <0.00001), and shorter postoperative hospital stay (WMD -0.57, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP vs LDP, 0.1% vs 1.0%, p=0.03). 2. Multivariate analysis revealed that male sex [OR (95%CI): 3.21(1.42-7.27), p=0.005], body mass index [OR (95% CI): 1.13(1.01-1.27), p=0.029], tumor located at the pancreas neck [OR (95%CI): 3.89(1.39-10.87), p =0.010], pancreatic resection line at the neck [OR (95%CI): 3.05(1.09-8.57), p =0.034] and splenic artery type B [OR (95%CI): 3.21(1.06-9.74), p=0.039] were independent risk factors for RDP surgical difficulty. Based on the above related factors, a nomogram was developed, which showed good discrimination, calibration and clinical validity.

Conclusion: With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. Male sex, body mass index, tumor located at the neck of the pancreas, pancreatic resection line at the neck and splenic artery type B may be associated with RDP difficulty level. A nomogram including these factors is developed to assess the difficulty level of surgery, so as to help surgeons choose patients suitable for them and ensure surgery safety.