Neoadjuvant therapy and minimally invasive surgery for pancreatic cancer: current evidence and surgical decision-making

Neoadjuvant therapy (NAT) is standard care for borderline resectable and locally advanced pancreatic cancer (PC). While minimally invasive surgery (MIS) is increasingly utilized post-NAT, surgical decision-making and technical feasibility remain debated. This review evaluates current evidence on patient selection, surgical timing, and technical strategies for MIS following NAT. A structured search was conducted in PubMed/MEDLINE and OpenAlex, supplemented by a manual search of landmark trials, consensus guidelines, and technical studies focusing on MIS following NAT for PC. Data on oncological radicality, perioperative outcomes, and vascular reconstruction were synthesized. Patient selection requires multidisciplinary evaluation integrating radiographic response and CA19-9 normalization. Post-NAT laparoscopic and robotic pancreatic resections achieve R0 resection rates, lymph node yields, and overall survival comparable to open surgery, with added benefits of reduced overall morbidity and shorter hospital stays in selected cohorts. Key technical approaches facilitating MIS in this setting include selective staging laparoscopy, artery-first dissection to establish resectability, arterial divestment preserving main vessels, standardized portal/superior mesenteric vein reconstruction, and adaptive anastomotic techniques tailored to therapy-induced fibrotic pancreatic parenchyma. MIS following NAT is safe, feasible, and oncologically sound when performed by experienced surgical teams in high-volume centers. Prospective studies and molecular response markers are warranted to further refine patient selection.