Minimally invasive pancreaticoduodenectomy: A bibliometric method applied to the top one hundred cited articles

Abstract

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) is considered one of the most complex procedures in general surgery. The number of articles on MIPD has been increasing annually. However, published reports often have complex research directions, and the focal points frequently change. Therefore, a comprehensive review and organization of the literature in this field is necessary.

AIM

To summarize current research, predict future hotspots and trends, and provide insights for MIPD development.

METHODS

To conduct the study, the Web of Science Core Collection was searched for relevant articles. The analysis focused on the top 100 articles in the field. Two widely used bibliometric tools, CiteSpace and VOSviewer, were used to examine various aspects, including research directions, authors, countries, institutions, journals, and keywords.

RESULTS

The top 100 articles were published between 2005 and 2022, with the majority originating from the United States (n = 51). Among the contributing institutions, Pancreas Center of the University of Chicago and the Health System of the University of Chicago had the highest number of publications (n = 17). In terms of individual authors, “Zeh HJ” and “Zureikat AH” led with 13 articles each. The high-frequency keywords in the literature encompassed three main areas: Surgical modality, perioperative outcomes, and the learning curve. These keywords were further categorized into seven primary clusters, with the largest being “laparoscopic pancreaticoduodenectomy”.

CONCLUSION

The most influential studies predominantly originate from the United States, and there is growing interest in robotic surgery. Despite MIPD’s potential benefits, further research is required to address technical challenges and improve outcomes.

Key Words: Minimally invasive pancreatoduodenectomy; Laparoscopic surgery; Robotic surgery; Bibliometric analysis; Citation analysis

Core Tip: This study presents a comprehensive bibliometric analysis of highly cited literature in the realm of minimally invasive pancreaticoduodenectomy. It elucidates the evolution of research trends, particularly emphasizing the rise of robotic surgical techniques and their gradual dominance over traditional laparoscopic approaches. Additionally, the analysis highlights the preeminent role of the United States in this field and identifies key research hotspots, including surgical modalities, perioperative outcomes, and learning curves. Despite considerable advancements, further investigation is warranted to address technical challenges and enhance patient outcomes in the future.

INTRODUCTION

Pancreaticoduodenectomy (PD) is a complex surgical procedure that has garnered substantial attention[1] from the surgical community since its inception in 1935. The evolution of PD[2] has seen a transition from conventional open PD (OPD) to minimally invasive surgeries (MIS), encompassing laparoscopic PD (LPD), hand-assisted LPD, and robotic-assisted PD[3]. MIS has become the standard treatment for specific gastrointestinal malignancies due to its advantages, including reduced blood loss, expedited recovery, and shorter hospital stays[4,5]. However, the progress of minimally invasive techniques within the PD domain remains sluggish, with widespread adoption limited to a select number of advanced medical centers[6,7]. Although an extensive body of literature exists regarding minimally invasive PD (MIPD), the research landscape is intricate and varied, with publication trends subject to frequent fluctuations. Consequently, a thorough review and organization of the literature in this field is essential.

Bibliometrics is a scientific methodology employing software tools such as CiteSpace and VOSviewer for the visual analysis of articles, focusing on fundamental elements such as countries, institutions, journals, authors, and keywords[8]. This approach offers invaluable insights for swiftly identifying research status and emerging hotspots. It has been widely utilized in various surgical disciplines, including spinal surgery[9], thoracic surgery[10], and other medical fields[11]. This study analyzed the top 100 most-cited articles pertaining to MIPD, constructing visualization maps to summarize the current research landscape and predict future hotspots. The findings aim to assist researchers in building a robust knowledge base and generating innovative ideas for the future advancement of MIPD.

MATERIALS AND METHODS

Literature source and retrieval strategy

The Web of Science Core Collection (WOSCC) is a premier database extensively utilized by researchers as a primary resource for discovering and acquiring the latest knowledge in various fields. This comprehensive collection encompasses over 15000 journals and 50 million categorized documents, spanning 251 categories across 150 distinct research areas. Furthermore, the WOSCC offers essential components for bibliometric analysis, including citation counts, abstracts, author affiliations, journals, keywords, and geographic information related to institutions and countries.

Figure 1 illustrates the article selection process employed in this study. The WOSCC was queried on April 1, 2024, without imposing any limitations on publication dates, resulting in a total of 1857 articles retrieved. These articles were organized in descending order based on citation counts. Ultimately, two researchers independently selected the top 100 articles deemed most relevant to molecular imaging in precision diagnostics (MIPD). In cases of disputed articles, a third researcher was designated to make the final decision regarding their inclusion. Consequently, a subset of 100 articles, published between 2005 and 2022, was incorporated into the bibliometric analysis.

Figure 1 Process for the analysis of 100 highly cited literature using bibliometric analysis.

Statistical analysis

For quantitative analysis and visualization, the software programs CiteSpace (version 6.2.R2) and VOSviewer (version 1.6.1) were utilized, chosen for their robust capabilities in citation network visualization and research trend detection. These widely recognized bibliometric tools, developed by Drexel University[12] and Leiden University[13], respectively, are Java-based applications that transform extensive datasets into visual representations. This visualization clearly delineates the distribution of scholarly contributions, the evolution of scientific knowledge, and the structural relationships within a particular discipline. In the network graphs produced, distinct nodes represent various elements such as institutions, authors, and keywords, with the size of each node corresponding to the quantity or frequency of its respective element. The connections between nodes reflect relationships such as co-occurrence, collaboration, or citation links, thereby emphasizing the degree of association among these elements. Collaboration network graphs were generated to visualize the interconnections among authors, countries, and institutions. Additionally, a co-citation analysis of the literature was performed to evaluate the relationships among cited works. To identify emerging trends, co-occurrence and clustering analyses of keywords were conducted, alongside an examination of emerging terms and the temporal trends of keywords, which revealed the research frontiers and hotspots within the domain of MIPD.

RESULTS

Trends in publication and co-citation analysis of the top 100 articles

We performed a comprehensive analysis of the publication trends (Figure 2) and co-citation patterns (Table 1) of the top 100 cited articles on MIPD. As shown in Figure 2, the publication period for these articles spanned from 2005 to 2022, with citation counts ranging from 27 to 318 and an average of 83.7 citations per article. This trend underscores the increasing interest and importance of the field over time. Notably, among the analyzed articles, 53 were dedicated to LPD, 32 focused on robotic PD (RPD), and 15 encompassed both themes. Since 2009, the number of published articles has significantly risen, indicating a steady upward trend. However, it is important to note that the number of LPD-related articles has gradually declined since 2015. In contrast, although RPD-related publications began to increase markedly after 2014, they have recently shown a trend of equalling LPD in terms of publication volume. Table 1 highlights the most highly co-cited articles within the domain, which are often considered foundational and influential works. Among these, seven articles addressed LPD, two focused on RPD, and one was related to hybrid laparoscopic abdominal PD. Furthermore, half of these seminal articles compared the outcomes of minimally invasive vs open surgeries, underscoring their critical role in shaping research directions in this field.

Figure 2 Publication trends of articles in different directions in the top 100 most cited articles (top 100). MIPD: Minimally invasive pancreaticoduodenectomy; LPD: Laparoscopic pancreaticoduodenectomy; RPD: Robotic pancreaticoduodenectomy.

Table 1 Top 10 highly co-cited articles among the top 100 most cited articles.

Rank	Title	Year	Journal	First author	Co-citation count
1	Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches?	2014	Ann Surg	Croome KP	31
2	Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System	2012	J Am Coll Surgeons	Asbun HJ	27
3	Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience	2010	Arch Surg-Chicago	Kendrick ML	26
4	Laparoscopic robotic-assisted pancreaticoduodenectomy: a case-matched comparison with open resection	2012	Surg Endosc	Chalikonda S	21
5	250 robotic pancreatic resections: safety and feasibility	2013	Ann Surg	Zureikat AH	19
6	Minimally invasive versus open pancreaticoduodenectomy for cancer: Practice patterns and short-term outcomes among 7061 patients	2015	Ann Surg	Adam MA	18
7	Assessment of quality outcomes for robotic pancreaticoduodenectomy: Identification of the learning curve	2015	Jama Surg	Boone BA	17
8	The first decade of laparoscopic pancreaticoduodenectomy in the United States: Costs and outcomes using the nationwide inpatient sample	2016	Surg Endosc	Tran TB	14
9	Evolution in techniques of laparoscopic pancreaticoduodenectomy: A decade long experience from a tertiary center	2009	J Hepato-Biliary-Pan	Palanivelu C	14
10	Can laparoscopic pancreaticoduodenectomy be safely implemented?	2011	J Gastrointest Surg	Zureikat AH	14

Author collaboration and co-occurrence analysis

The analysis of author contributions reveals significant research relationships and collaborations in the field. A total of 632 authors contributed to the top 100 articles. Table 2 lists the top ten authors based on the number of publications. Among these, six authors from the University of Pittsburgh collaboratively published 14 articles. Notably, “Zeh HJ” and “Zureikat AH” from the United States are tied for first place with 13 published articles each, with “Zeh HJ” achieving the highest H-index (n = 81) among the group. Additionally, authors from Italy, China, and India also feature in the top ten, highlighting the international scope of research contributions in this field. Collaboration among authors reflects the intricate connections among researchers in this field. As illustrated in Figure 3A, the author network is relatively dispersed, characterized by fewer tight connections. Notably, the American author cluster centered around “Zeh HJ” and “Zureikat AH” demonstrates a concentrated relationship, forming the largest cluster in the clustering diagram.

Figure 3 Visualization networks of authors, countries, institutions, and journals for the top 100 most cited articles (top 100). A: Co-authorship network; B: Country collaboration network; C: Institution collaboration network; D: Dual-map overlay of journals.

Table 2 Top 10 authors in terms of number of articles published.

Rank	Author	Frequency	H-index	Country	Organization
1	Zeh HJ	13	81	United States	University of Pittsburgh
2	Zureikat AH	13	42	United States	University of Pittsburgh
3	Hogg ME	11	36	United States	University of Pittsburgh
4	Zenati MS	9	34	United States	University of Pittsburgh
5	Boggi U	7	49	Italy	University of Pisa
6	Bartlett DL	6	70	United States	University of Pittsburgh
7	Kendrick ML	6	45	United States	Mayo Clinic
8	Peng B	6	19	China	Sichuan University
9	Moser AJ	5	32	United States	University of Pittsburgh
10	Palanivelu C	5	27	India	Gem Hosp & Res Ctr

Analysis of national, institutional, and journal collaboration networks

To further elucidate the research landscape, we constructed visual graphs for the national, institutional, and journal networks. The findings are summarized in Table 3, which lists the top ten countries, institutions, and journals by publication volume. According to Figure 3B, the analysis of the top 100 articles indicates contributions from 18 countries, with the United States (n = 51), China (n = 19), and Italy (n = 12) leading in publication output. Figure 3C depicts the collaboration patterns among 157 institutions, highlighting significant contributions from Pancreas Center of the University of Chicago and the Health System of the University of Chicago (PCSHE) (n = 17), the University of Pittsburgh (n = 16), and the University of Texas System (n = 12). Furthermore, Figure 3D illustrates the interrelationships among 31 journals in this field, with Surgical Endoscopy having the highest publication count (n = 23).

Table 3 Top 10 countries, institutions, and journals by publication count.

Rank	Countries	Count	Institutions	Count	Journals	Count
1	United States	51	Pennsylvania Commonwealth System of Higher Education	17	Surg Endosc	23
2	China	19	University of Pittsburgh	16	Ann Surg	15
3	Italy	12	University of Texas System	12	J Gastrointest Surg	8
4	South Korea	8	Mayo Clinic	10	J Am Coll Surg	5
5	France	6	NorthShore University Health System	8	Surgery	4
6	Netherlands	5	University of Pisa	7	JAMA Surg	4
7	India	5	University of Chicago	6	J Hepato-Biliary-Pancreat Sci	4
8	Japan	4	Sichuan University	6	Hpb	4
9	England	4	Vrije Universiteit Amsterdam	5	Ann Surg Oncol	4
10	Spain	4	University of Amsterdam	5	Am J Surg	3

In terms of collaboration, Figure 3B shows that the United States occupies a central position within the network, exhibiting robust connections with other countries. Figure 3C underscores the close collaborative relationships of PCSHE, the University of Pittsburgh, and the University of Texas System with various institutions, placing them at the core of the collaboration network. Interestingly, while the Mayo Clinic, University of Chicago, and Sichuan University demonstrate substantial publication outputs, their collaborative ties with other institutions appear to be less dense. The double-map overlaying atlas of journals (Figure 3D) provides insights into the distribution of major journals for both articles and citations within this field. The left side highlights primary journals that publish articles, predominantly from medical and clinical domains, while the right side showcases the major journals cited, spanning diverse fields with a notable emphasis on health, nursing, and medicine.

Keyword co-occurrence analysis

Bibliometric analysis, centered on keyword examination, serves as a pivotal tool for discerning research patterns and forecasting future scholarly directions. After filtering out non-essential keywords such as “pancreaticoduodenectomy”, “surgery”, and “minimally invasive pancreaticoduodenectomy”, we identified 267 relevant keywords from the top 100 articles. Table 4 highlights the ten most frequent keywords, among which “laparoscopic pancreaticoduodenectomy” stands out due to its significant recurrence and co-occurrence rates. The co-occurrence network depicted in Figure 4A reveals that the most interconnected keywords pertain to three critical facets of MIPD: The surgical approach, perioperative outcomes, and the learning curve associated with the procedure. Notably, terms linked to perioperative outcomes are predominantly represented, including “outcomes (n = 41)”, “complications (n = 32)”, and “postoperative pancreatic fistula (n = 26)”.

Figure 4 Visualization networks of keywords for the top 100 most cited articles (top 100). A: Co-occurrence analysis graph; B: Keyword cluster map.

Table 4 Main keywords of the top 100 most cited articles.

Rank	Keywords	Frequency	Centrality
1	Laparoscopic pancreaticoduodenectomy	41	0.02
2	Outcome	41	0.02
3	Ductal adenocarcinoma	39	0.33
4	International study group	37	0.04
5	Complications	32	0.01
6	Postoperative pancreatic fistula	26	0.1
7	Cancer	25	0.13
8	Resection	25	0.07
9	Pylorus preserving pancreaticoduodenectomy	19	0.15
10	Learning curve	18	0.02

Visual map analysis of keyword clustering

To decode the thematic structure of this research area, we executed a cluster analysis on the keywords using the visualization tool CiteSpace, resulting in the categorization of the 267 keywords into seven distinct clusters as shown in Figure 4B. These encompass key topics such as “laparoscopic pancreaticoduodenectomy”, “learning curve”, “ductal adenocarcinoma”, “pancreaticojejunostomy”, “complications”, “robotic surgery”, and “pancreatic fistula”. The cluster dominated by “laparoscopic pancreaticoduodenectomy” emerged as the most prominent one.

Visual map analysis of time distribution of keywords

In our visual map analysis of keyword time distribution, we probed the evolution of research themes over time to further elucidate future research trajectories (Figure 5A and B). The analysis, illustrated in Figure 5A, identifies 25 keywords experiencing the highest citation bursts across various periods. Initially dominant keywords include “pancreas”, “cancer”, and “ductal adenocarcinoma”, transitioning to “single institution”, “early experience”, “survival”, and “resection” in the mid-term. More recent focus areas have shifted to “postoperative pancreatic fistula”, “learning curve”, “technical performance”, “hospital volume”, and “risk factors”. Concurrently, Figure 5B charts the temporal shifts within the seven clusters previously described, noting that themes such as “learning curve”, “pancreaticojejunostomy”, and “pancreatic fistula” have maintained their relevance.

Figure 5 Visualization of keyword trends over time in the top 100 most cited articles (top 100). A: Keywords with the strongest citation bursts identified using CiteSpace, highlighting emerging research trends; B: Timeline graphs of different keyword clusters, illustrating the evolution and shifts in research focus over time.

DISCUSSION

Since the groundbreaking introduction of LPD by Gagner et al[14] in 1994, the domain of MIS in PD has seen considerable growth. Our bibliometric analysis of the top 100 cited articles on MIPD highlights significant shifts in research focus and emerging trends, particularly emphasizing the increasing adoption of robotic and laparoscopic techniques. Consequently, a thorough review of seminal works in MIPD is imperative. In our study, we utilized tools such as CiteSpace and VOSviewer to perform a bibliometric analysis of the most influential articles in this field. The goal was to map the current research terrain within MIPD, pinpoint ongoing hotspots, and forecast potential future developments.

Among the top 100 articles, 68% concentrated on laparoscopic methods. Despite nearly three decades of advancement, views on the safety and feasibility of laparoscopy remain mixed. The analysis affirms that, in high-volume centers with skilled surgeons, laparoscopic procedures[15,16] can be conducted with safety. Notably, three randomized controlled trials among these top-cited works substantiate that LPD offers a reduced hospital stay compared to traditional OPD. However, these studies have their drawbacks. The research by Palanivelu et al[17] and Poves et al[18], though influential, suffered from small sample sizes and were limited to single-center scopes. Conversely, the study by Wang et al[16], despite a more substantial sample size and being conducted in a high-volume hospital, failed to demonstrate notable benefits for LPD. Furthermore, due to specific healthcare policies in China, this study faced challenges in patient selection. In a contrasting vein, skepticism about LPD’s safety persists[19,20], as evidenced by a comprehensive multicenter randomized controlled trial by van Hilst et al[19], which reported significantly higher complication and mortality rates for LPD compared to OPD, without a significant difference in hospital stays. This latter study was hampered by a less steep learning curve and lower patient volumes, highlighting critical areas for future research and methodology refinement in assessing LPD’s efficacy.

In addition to laparoscopic techniques, the da Vinci surgical system has garnered increasing interest among surgeons since the first report of RPD in 2003[21]. As illustrated in Figure 2, while the total number of publications on RPD remains relatively low, there has been a notable upward trend in recent years, nearing the publication volume of LPD. The lower total number of RPD articles can be attributed to its delayed adoption compared to LPD. Robotic surgery, despite the complex technical demands and steep learning curve associated with laparoscopy, presents several advantages, including enhanced visualization, the elimination of surgeon hand tremors, improved maneuverability of instruments, and a more streamlined workflow[22,23]. Furthermore, multiple high-quality studies have demonstrated the safety and feasibility of RPD in appropriately selected patients, indicating potential benefits such as a reduced learning curve, decreased estimated blood loss, lower conversion rates, higher lymph node retrieval rates, reduced incidence of delayed gastric emptying, and shorter postoperative hospital stay[24,25]. However, the generalizability of these benefits necessitates further investigation through randomized clinical trials.

In the domain of MIPD, the United States leads with the highest number of publications (n = 51), with six institutions ranking among the global top ten, reflecting robust research capabilities. Notable institutions, including the University of Pittsburgh, the University of Chicago, and those affiliated with the PCSHE, have significantly advanced MIPD technology through innovations in minimally invasive surgical instruments and intraoperative imaging. These institutions emphasize robotic surgery training, focusing on learning curves and quality assessments, which markedly enhance surgical precision and safety[26,27]. Collaborative efforts have refined standard MIPD procedures, leading to reductions in intraoperative bleeding and postoperative pancreatic fistula rates[24,28]. Among these, the University of Pittsburgh has made significant contributions to perioperative management, with research teams concentrating on the perioperative conditions of MIPD patients, particularly in postoperative early rehabilitation and monitoring, which have resulted in reduced complications and significantly improved patient survival rates and quality of life[29,30]. Centered around the University of Pittsburgh, a network of core institutions has emerged, driving numerous multi-institutional research projects that expand the scope and depth of research, accelerate the development of MIPD globally, and foster technological innovation in this field.

Since the introduction of MIPD, numerous authors have made significant contributions to this evolving field. Notably, authors Zeh HJ and Zureikat AH have distinguished themselves with the highest publication output, positioning them as central figures within the collaboration network graph and indicating their potential roles as leading experts in this area. In 2011, they published a seminal article addressing the fundamental aspects of RPD technology. This was followed by subsequent publications in 2012, 2016, and 2021, documenting their experiences with 50, 150, and 500 RPD cases, respectively[24,31,32]. Moreover, they contributed to an article in JAMA introducing a quality assessment tool for RPD technology, which has been widely cited and ranks fifth among the top 100 articles, providing critical insights for the dissemination and adoption of RPD practices[26]. Another prominent figure in this domain is Palanivelu C, primarily engaged in LPD research. Palanivelu contributed to the international expert consensus on laparoscopic techniques and the development of guidelines for minimally invasive pancreatic resection[33,34]. They have also reported their experiences with 75, 130, and 150 LPD cases in 2009, 2015, and 2018, respectively[35-37]. Furthermore, Palanivelu et al[17] conducted a randomized controlled trial comparing LPD with OPD, significantly advancing laparoscopic methodologies in pancreatic surgery.

Keyword analysis is instrumental in delineating research topics and identifying shifts in hotspots within a specific field, as well as forecasting future research trajectories. In this study, we analyzed seven pivotal research topics. Among these, three - namely “laparoscopic pancreaticoduodenectomy”, “pancreaticojejunostomy”, and “robotic surgery” - are particularly linked to surgical techniques. Notably, “laparoscopic pancreaticoduodenectomy” has emerged as the leading research topic, having been an early adopter of laparoscopic technology and thus accruing the highest publication count. Although “robotic surgery” was introduced later, it has evolved into a significant research area, with an increasing number of publications that rival or even exceed those of “laparoscopic pancreaticoduodenectomy”, indicating a promising avenue for further exploration in robotic surgery. Nonetheless, both laparoscopic and robotic surgeries continue to grapple with the challenge of pancreaticojejunostomy, a procedure often associated with severe postoperative complications, including pancreatic leaks and bleeding, which pose substantial risks to patient safety. Several researchers have proposed innovative strategies to mitigate these challenges. For instance, Wang et al[38] introduced the hybrid laparoscopic abdominal PD technique, which employs a mini-laparotomy approach combined with abdominal wall lifting to address the challenges associated with intracorporeal anastomosis. They posited that this hybrid method not only mitigates reconstruction difficulties but also shortens the learning curve, thereby facilitating the transition from open to LPD. Conversely, Poves et al[39] presented a laparoscopically assisted PD technique, which demonstrated a significant reduction in the rates of severe postoperative complications associated with LPD. In a recent study involving 238 LPD patients, a novel technique termed duct-to-mucosa pancreaticojejunostomy (referred to as Bing’s anastomosis) was proposed, showcasing a lower incidence of pancreatic fistula[40]. It is essential to recognize that the findings from these studies are constrained by their individual nature and lack the support of standardized, large-scale research to validate their reliability.

Additionally, beyond the previously mentioned clustering, these seven clusters encompassed two further clusters related to “complications” and “pancreatic fistula”. Notably, there was a significant representation of outcomes, with 41 instances classified under “outcome”, 32 under “complications”, and 26 under “postoperative pancreatic fistula”. Therefore, it is imperative to prioritize the monitoring of postoperative complications, particularly postoperative pancreatic fistula, in MIPD, where the estimated incidence rate ranges from 10% to 20%. Various risk factors linked to the occurrence of postoperative pancreatic fistula have been identified, including the choice of anastomotic technique, preoperative pancreatic inflammation, and elevated body mass index. While numerous prevention and treatment strategies have been proposed - including the judicious selection of anastomotic techniques, the application of biological sealants or reinforcement materials, and intraoperative drainage - there remains a notable absence of unified guidelines and consensus in this area. Consequently, there is a pressing need for further rigorously designed, large-scale studies to provide more reliable guidance.

While our analysis of the top 100 articles in the MIPD field offers valuable insights for those interested in engaging with or further exploring the field, it is crucial to acknowledge certain limitations. Firstly, our study was confined to literature within the WOSCC, thereby excluding potentially significant articles available in other databases. Secondly, our exclusion of non-English and non-article publications may have omitted seminal works in the field. Lastly, some pivotal articles published recently were excluded from our analysis due to their limited citation history. Despite these limitations, we believe our analysis will still be beneficial to the majority of researchers by providing fresh perspectives and fostering future developments in MIPD.

CONCLUSION

This study employs CiteSpace and VOSviewer for a bibliometric analysis of the top 100 most-cited articles in MIPD, highlighting key research countries, institutions, contributors, and significant research trends. Notably, institutions such as PCSHE in the United States and the University of Pittsburgh are central to the research efforts in this field, with researchers like “Zeh HJ” and “Zureikat AH” playing pivotal roles. The growing adoption of robotic technologies over traditional laparoscopic techniques indicates a shift towards robotic surgery, which is poised to influence future research directions in MIPD. Our findings also emphasize current research focus areas including anastomosis techniques, learning curves, and risk factors associated with postoperative pancreatic fistula. Moving forward, it is expected that future studies will delve deeper into these critical areas to enhance surgical outcomes in MIPD. While acknowledging the benefits of minimally invasive approaches, our analysis underscores the dynamic nature of surgical techniques and the continuous need for improvement in clinical practices.

ACKNOWLEDGEMENTS

We would like to express our heartfelt gratitude to the authors of this manuscript for their collaborative efforts in conducting this research. Their dedication and contributions have been instrumental in the successful completion of this study.