Initial experience with hand-assisted laparoscopic distal pancreatectomy

Fifty years of pancreas cancer care

Resulting from 50 years of innovation, operations for pancreatic neoplasms can now be performed safely, albeit with significant but manageable morbidity. Molecular diagnosis has allowed for the identification of multiple distinct histopathologies with variable natural histories. Observation is now a strategy for selected indolent cysts and some neuroendocrine neoplasms. For ductal pancreatic adenocarcinoma, a long-term cure remains elusive and will require more than surgical resection for meaningful progress.

Lending a hand for laparoscopic distal pancreatectomy: the optimal approach?

BACKGROUND

Both minimally invasive surgery (MIS) and open approaches for distal pancreatectomy are acceptable. MIS options include total laparoscopic/robotic (TLR) and hand-assist laparoscopy (HAL). When considering safety profile and specimen quality, the optimal approach is unknown.

METHODS

Patients who underwent distal pancreatectomy from 2010-2018 at two major academic institutions were included. Converted procedures were categorized into final approach. Ninety-day perioperative/pathologic outcomes of MIS and open were compared. Subset analyses between TLR vs HAL and HAL vs open were performed. Intent-to-treat analysis was performed.

RESULTS

Among 1006 patients, resection was performed by MIS in 35% (n = 352), open in 65% (n = 654). MIS had similar patient comorbidity profile as open but had increased operative time (183 vs 162 min; p < 0.01), lower estimated-blood-loss (EBL; 131 vs 341 mL; p < 0.01), fewer intraoperative blood transfusions (1.4 vs 5%; p < 0.01), shorter LOS (5.2 vs 7.2 days; p < 0.01). Tumor size was smaller (3.2 vs 4.4 cm; p < 0.01) with lower lymph node (LN) yield (14 vs 16; p < 0.01). When comparing HAL (n = 109) to TLR (n = 243), despite increased prior abdominal operations (60 vs 43%; p = 0.008), HAL had shorter operative time (167 vs 191 min; p < 0.01), similar length-of-stay (LOS; 5.4 vs 5.1 days; p = 0.27), and readmission rate (15 vs 13%; p = 0.47). When comparing HAL to open, the advantages of TLR approach persisted including lower EBL (171 vs 342 mL; p < 0.01), and shorter LOS (5.4 vs 7.2 days; p < 0.01). Although HAL had smaller tumors, it had a similar LN yield (16 vs 16; p = 0.80), and higher R0-rate (97 vs 83%; p < 0.01).

CONCLUSION

Hand-assist laparoscopy is safe and feasible for distal pancreatectomy as operative time, complication profile, lymph node yield, and R0-rates are similar to open procedures, while maintaining the associated the advantages of a total laparoscopic/robotic approach with reduced blood loss and shorter length-of-stay.

Propensity score-matched comparison of oncological outcomes between laparoscopic and open distal pancreatic resection

BACKGROUND

Selected studies have reported improved outcomes in laparoscopic compared with open distal pancreatic resection. Concerns regarding failure to achieve proper oncological resection and compromised long-term outcomes remain. This study investigated whether postoperative outcomes and long-term survival after laparoscopic distal pancreatectomy are comparable to those after an open procedure.

METHODS

This retrospective case-control study included patients who underwent distal pancreatectomy for resectable pancreatic adenocarcinoma between 2010 and 2013, identified from the National Cancer Database. Propensity score nearest-neighbour 1 : 1 matching was performed between patients undergoing laparoscopic or open distal pancreatectomy based on all relevant co-variables. The primary outcome was overall survival.

RESULTS

Of 1947 eligible patients, 605 (31·1 per cent) underwent laparoscopic distal pancreatectomy. After propensity score matching, two well balanced groups of 563 patients each were analysed. There was no difference in overall survival at 3 years after laparoscopic versus open distal pancreatectomy (41·6 versus 36·0 per cent; hazard ratio 0·93, 95 per cent c.i. 0·77 to 1·12; P = 0·457). The overall conversion rate was 27·3 per cent (165 of 605). Patients who underwent laparoscopic distal pancreatectomy had outcomes comparable to those of patients who had an open procedure with regard to median time to chemotherapy (50 versus 50 days; P = 0·342), median number of nodes examined (12 versus 12; P = 0·759); 30-day mortality (1·2 versus 0·9 per cent; P = 0·562); 90-day mortality (2·8 versus 3·7 per cent; P = 0·403), 30-day readmission rate (9·6 versus 9·2 per cent; P = 0·838) and positive margin rate (14·9 versus 18·5 per cent; P = 0·110). However, median duration of hospital stay was shorter in the laparoscopic group (6 versus 7 days; P < 0·001).

CONCLUSION

Laparoscopic distal pancreatectomy is an acceptable alternative to open distal pancreatectomy with no detriment to survival.

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000–2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Evolving application of minimally invasive cancer operations at a tertiary cancer center

BACKGROUND

Patients and providers are increasingly interested in the utilization, safety, and efficacy of minimally invasive surgery (MIS). We reviewed 11 years of MIS resections (laparoscopic and robotic) for intra-abdominal malignancies.

METHODS

Patients who underwent gastrectomy, distal pancreatectomy, hepatic resection, and colorectal resection between 2004 and 2014 were identified. Cases were categorized as open, laparoscopic, and robotic based on the initial operation approach. Diagnostic laparoscopies were excluded.

RESULTS

Of the 10 039 patients who underwent the above procedures, between 2004 and 2014, 2832 (28%) were MIS. In 2004, 12% (100/826) of all resections were performed with MIS approaches, rising to 23% (192/821) of all resections by 2009 and 44% (484/1092) in 2014. The number of open resections has remained largely stable: 726 (88% of all resections) in 2004 and 608 (56% of all resections) in 2014. Initially, laparoscopy experienced incremental adoption. Robotic surgery was implemented in 2009 and is currently the dominant MIS approach, accounting for 76% (368/484) of all MIS resections in 2014. Overall mortality has remained less than 1%.

CONCLUSIONS

While maintaining patient safety, utilization of MIS techniques has increased substantially since 2004, particularly for gastric and colorectal resections. Since 2009 robotic surgery is the predominant MIS approach.

Short-term outcomes after distal pancreatectomy: Laparotomy vs. laparoscopy - A single-center series

Background

Laparoscopic distal pancreatectomy was introduced 15 years ago, but it is still not widely used. The aim of the study was to compare the postoperative complications and length of stay between open and laparoscopic distal pancreatectomy.

Materials and methods

A search of our institutional pancreas database was performed. All consecutive distal pancreatectomy patients from 2000 to 2015 were identified. Demographics, peri- and postoperative outcomes were reviewed. Postoperative complications were graded using Clavien classification. Standard statistical analyses were performed.

Results

One hundred and five patients underwent distal pancreatectomy (45 women, 60 men, median age of 63 years). Seventy-nine cases were performed open and 26 by laparoscopy (conversion rate from laparoscopy to laparotomy: 7/26). Characteristics of both groups were similar. The tumor proportion was similar in both groups (56/79 and 23/26, p = 0.114). Overall complication rate was 41/79 (52%) in the open group and 9/26 (36%) in the laparoscopy group (p = 0.175). Two patients died during hospital stay in the open group compared to 0 in the laparoscopy group (p = 1). The fistula rates were comparable (17/79 and 5/26, p = 1). Median length of stay was shorter for the laparoscopy group (8 vs. 12 days, p < 0.001), as well as the median intermediate care stay (1 vs. 3 days, p = 0.004).

Conclusion

Short-term outcomes after open and laparoscopic distal pancreatectomy regarding postoperative complications and mortality were similar, but length of stay was significantly shorter for the laparoscopic approach. Hence, laparoscopic distal pancreatectomy should be offered to all suitable patients.

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Laparoscopy has been recently used more frequently for distal pancreatectomy.

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Postoperative complications and oncologic outcomes were similar in this study.

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Length of stay was shorter for the patients operated by laparoscopy.

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Laparoscopy should be offered when technically feasible.

Laparoscopic distal pancreatectomy

After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.

Laparoscopic Distal Pancreatectomy with or without Preservation of the Spleen for Solid Pseudopapillary Neoplasm

Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas. Laparoscopic distal pancreatectomy (DP) is a feasible and safe procedure, and successful spleen preservation rates are higher using a laparoscopic approach. We hypothesized that certain patients with SPN would be good candidates for laparoscopic surgery; however, few surgeons have reported laparoscopic DP for SPN. We discuss the preoperative assessment and surgical simulation for two SPN cases. A simulation was designed because we consider that a thorough preoperative understanding of the procedure based on three-dimensional image analysis is important for successful laparoscopic DP. We also discuss the details of the actual laparoscopic DP with or without splenic preservation that we performed for our two SPN cases. It is critical to use appropriate instruments at appropriate points in the procedure; surgical instruments are numerous and varied, and surgeons should maximize the use of each instrument. Finally, we discuss the key techniques and surgical pitfalls in laparoscopic DP with or without splenic preservation. We conclude that experience alone is inadequate for successful laparoscopic surgery.

Laparoscopic distal pancreatectomy for adenocarcinoma: safe and reasonable?

As a result of technological advances during the past two decades, surgeons now use minimally invasive surgery (MIS) approaches to pancreatic resection more frequently, yet the role of these approaches for pancreatic ductal adenocarcinoma resections remains uncertain, given the aggressive nature of this malignancy. Although there are no controlled trials comparing MIS technique to open surgical technique, laparoscopic distal pancreatectomy for pancreatic adenocarcinoma is performed with increasing frequency. Data from retrospective studies suggest that perioperative complication profiles between open and laparoscopic distal pancreatectomy are similar, with perhaps lower blood loss and fewer wound infections in the MIS group. Concerning oncologic outcomes, there appear to be no differences in the rate of achieving negative margins or in the number of lymph nodes (LNs) resected when compared to open surgery. There are limited recurrence and survival data on laparoscopic compared to open distal pancreatectomy for pancreatic adenocarcinoma, but in the few studies that assess long term outcomes, recurrence rates and survival outcomes appear similar. Recent studies show that though laparoscopic distal pancreatectomy entails a greater operative cost, the associated shorter length of hospital stay leads to decreased overall cost compared to open procedures. Multiple new technologies are emerging to improve resection of pancreatic cancer. Robotic pancreatectomy is feasible, but there are limited data on robotic resection of pancreatic adenocarcinoma, and outcomes appear similar to laparoscopic approaches. Additionally fluorescence-guided surgery represents a new technology on the horizon that could improve oncologic outcomes after resection of pancreatic adenocarcinoma, though published data thus far are limited to animal models. Overall, MIS distal pancreatectomy appears to be a safe and reasonable approach to treating selected patients with pancreatic ductal adenocarcinoma, though additional studies of long-term oncologic outcomes are merited. We review existing data on MIS distal pancreatectomy for pancreatic ductal adenocarcinoma.

Laparoscopic pancreatectomy: Indications and outcomes

The application of minimally invasive approaches to pancreatic resection for benign and malignant diseases has been growing in the last two decades. Studies have demonstrated that laparoscopic distal pancreatectomy (LDP) is feasible and safe, and many of them show that compared to open distal pancreatectomy, LDP has decreased blood loss and length of hospital stay, and equivalent post-operative complication rates and short-term oncologic outcomes. LDP is becoming the procedure of choice for benign or small low-grade malignant lesions in the distal pancreas. Minimally invasive pancreaticoduodenectomy (MIPD) has not yet been widely adopted. There is no clear evidence in favor of MIPD over open pancreaticoduodenectomy in operative time, blood loss, length of stay or rate of complications. Robotic surgery has recently been applied to pancreatectomy, and many of the advantages of laparoscopy over open surgery have been observed in robotic surgery. Laparoscopic enucleation is considered safe for patients with small, benign or low-grade malignant lesions of the pancreas that is amenable to parenchyma-preserving procedure. As surgeons’ experience with advanced laparoscopic and robotic skills has been growing around the world, new innovations and breakthrough in minimally invasive pancreatic procedures will evolve.

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.

Minimally invasive radical pancreatectomy for left-sided pancreatic cancer: Current status and future perspectives

Minimally invasive distal pancreatectomy with splenectomy has been regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions. However, its application for left-sided pancreatic cancer is still being debated. The clinical evidence for radical antegrade modular pancreatosplenectomy (RAMPS)-based minimally invasive approaches for left-sided pancreatic cancer was reviewed. Potential indications and surgical concepts for minimally invasive RAMPS were suggested. Despite the limited clinical evidence for minimally invasive distal pancreatectomy in left-sided pancreatic cancer, the currently available clinical evidence supports the use of laparoscopic distal pancreatectomy under oncologic principles in well-selected left sided pancreatic cancers. A pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney positioned more than 1 or 2 cm away from the celiac axis is thought to constitute a good condition for the use of margin-negative minimally invasive RAMPS. The use of minimally invasive (laparoscopic or robotic) anterior RAMPS is feasible and safe for margin-negative resection in well-selected left-sided pancreatic cancer. The oncologic feasibility of the procedure remains to be determined; however, the currently available interim results indicate that even oncologic outcomes will not be inferior to those of open radical distal pancreatosplenectomy.

200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

INTRODUCTION

Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease.

METHODS

From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed.

RESULTS

A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation.

CONCLUSIONS

Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.

Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis

OBJECTIVE

To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques.

BACKGROUND

LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP.

METHODS

A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model.

RESULTS

Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality.

CONCLUSIONS

LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

Perioperative outcomes of laparoscopic and open distal pancreatectomy: our institution's 5-year experience

BACKGROUND

Application of minimally invasive techniques in the surgical management of distal pancreatic lesions is increasing. Despite this, numbers of laparoscopic distal pancreatectomy remain low and limited to treatment of benign and premalignant lesions.

METHODS

Retrospective analysis of 31 patients who underwent distal pancreatectomy from 2005 to 2010. Patients were grouped according to mode of surgical access: open (ODP) or laparoscopic (LDP). Perioperative parameters were compared.

RESULTS

Twenty-one (67.7%) patients underwent ODP and 10 (32.3%) LDP (median age 61; 80.0% females in LDP group, p = 0.030). Postoperative morbidity rate were comparable between the two groups. In the LDP group, there were significantly lower estimated blood loss (p < 0.001) and amount of blood transfusion (p = 0.001), smaller tumor size (p = 0.010) and fewer lymph nodes harvested (p = 0.020), shorter postoperative length of stay (p = 0.020), and shorter length of stay in surgical high dependency (p = 0.001).

CONCLUSION

LDP is a safe, efficient technique for resection of benign and premalignant pancreatic lesions. Indices reflecting perioperative outcomes in this study are highly competitive with those in other major centers.

Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience

BACKGROUND

As compared with open distal pancreatectomy, laparoscopic distal pancreatectomy (LDP) is associated with lower morbidity and shorter hospital stays. Existing reports do not elucidate trends in patient selection, technique, and outcomes over time. We aimed to determine outcomes after LDP at a specialized center, analyze trends of patient selection and operative technique, and validate a complication risk score (CRS).

STUDY DESIGN

Patients undergoing LDP between January 2000 and January 2011 were identified and divided into 2 equal groups to represent our early and recent experiences. Demographics, tumor characteristics, operative technique, and perioperative outcomes were examined and compared between groups. A CRS was calculated for the entire cohort and examined against observed outcomes.

RESULTS

A total of 132 LDPs were attempted, of which 8 (6.1%) were converted to open procedures. Thirty-day overall and major complication rates were 43.2% and 12.9%, respectively, with mortality < 1%. Pancreatic fistulas occurred in 28 (21%) patients, of which 14 (11%) were clinically significant. Recent LDPs (n = 66) included patients with increasingly severe comorbidities (Charlson scores > 2, 40.9% vs 16.7%, p = 0.003), more proximal tumors (74.2% vs 26.2%, p < 0.001), more extended resections (10.6 vs 8.3 cm, p < 0.001), shorter operative times (141 vs 172 minutes, p = 0.007), and less frequent use of a hand port (25.8% vs 66.6%, p < 0.001). No significant differences were found in perioperative outcomes between the groups. As compared with the hand access technique, the total laparoscopic approach was associated with shorter hospital stays (5.3 vs 6.8 days, p = 0.032). Increasing CRS was associated with longer operative time, significant fistulas, wound infections, blood transfusions, major complications, ICU readmissions, and rehospitalizations.

CONCLUSIONS

This large, single-institution series demonstrates that despite a shift in patient selection to sicker patients with more proximal tumors, similar perioperative outcomes can be achieved with laparoscopic distal pancreatectomy. The CRS appears to be a reliable preoperative assessment tool for assessing other adverse perioperative outcomes in addition to predicting overall complications and fistulas as originally published.

Laparoscopy in pancreatic tumors

Recently, increasing number of manuscripts - original articles and case reports have attempted to provide evidence of the forays of minimal access surgery into pancreatic diseases. Many, based on the lack of Level I evidence, still believe that laparoscopy in pancreatic surgery is experimental. This article attempts to look into data exploring the existing use of minimally invasive surgery in pancreatic disease to answer a vital question - what does the evidence say on the current status of laparoscopic surgery in pancreatic tumors.

Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. We analyzed the clinical characteristics of the largest series of patients to date who underwent LDP at a single center, as well as their outcomes, to reassess the surgical paradigm for left pancreatic resection.

METHODS

We retrospectively reviewed the records of 359 patients who underwent LDP at Asan Medical Center, Seoul, Korea, for pancreatic neoplasms between March 2005 and December 2010.

RESULTS

Of the 359 patients, 323 (90%) had benign or low-grade malignant neoplasms and 36 (10%) had malignancies. The most common diagnosis was intraductal papillary mucinous neoplasm (IPMN) in 72 patients (21.2%). There were 24 patients (6.7%) with pancreatic ductal adenocarcinoma (PDAC). We found that 178 patients (49.6%) underwent spleen-preserving LDP (SP-LDP): 150 (84.3%) by main splenic vessel preservation, and 28 (15.7%) supported by short gastric and gastroepiploic vessels (Warshaw technique). Postoperative complications occurred in 43 (12%) patients, including 25 (7%) with pancreatic fistula (ISGPF grade B, C), but there was no death. Median operative time was 195 (range, 78-480) min, and median postoperative hospital stay was 8 (range, 4-37) days. The proportion of patients with pancreatic lesions who underwent LDP increased from 8.6% in 2005 to 66.9% in 2010. Kaplan-Meier analysis showed that the 1- and 2-year overall survival rates in the 24 patients with PDAC were 85.2% each.

CONCLUSIONS

LDP is feasible, safe, and effective for the treatment of benign and low-grade malignant lesions of the pancreas. The increased use of LDP for left-sided pancreatic lesions, including malignant lesions, represents a paradigm shift from open distal pancreatectomy.

Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature

BACKGROUND

Advances in operative techniques and technology have facilitated laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD).

METHODS

All distal pancreatectomies were attempted laparoscopically, while selected patients underwent LPD. The literature was systematically reviewed.

RESULTS

Between 2002 and 2008, 21 patients underwent LDP (n=14) or LPD (n = 7). The mean operating time, blood loss, and hospital stay after LDP were 265 min, 262 ml, and 7.7 days, respectively, and after LPD they were 628 min, 350 ml, and 11.1 days, respectively. The conversion, morbidity, pancreatic fistula, readmission, reoperation, and mortality after LDP were 7.1, 35.7, 28.4, 28.4, 0, and 7.1% respectively, and after LPD they were 0, 28.6, 14.3, 28.6, 0, and 0% respectively. The literature review identified 987 LDP and 126 LPD. Most LDP were for benign disease (83.9%) while most LPD were for malignancy (91.5%). The mean operating time, morbidity, pancreatic fistula, mortality, and hospital stay after LDP were 221.5 min, 24.7%, 16.4%, 0.4%, and 7.7 days, respectively, and after LPD they were 448.3 min, 28.6%, 11.6%, 2.1%, and 16 days, respectively.

CONCLUSION

LDP, particularly for benign disease and low-grade malignancy, is increasingly becoming the gold standard approach in experienced hands. In selected patients, LPD is feasible and safe. Long-term follow-up data are needed.

Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies

BACKGROUND

The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed.

METHODS

A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.

RESULTS

For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.89], major complications (OR, 0.57; 95% CI, 0.34-0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19-0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47-0.98).

CONCLUSIONS

The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.

Laparoscopic distal pancreatectomy: evolution of a technique at a single institution

BACKGROUND

The pancreas remains an organ for which routine laparoscopic resection is uncommon.

STUDY DESIGN

This is a review of all distal pancreatectomies performed between January 2003 and December 2009 at Memorial Sloan-Kettering Cancer Center. Variables were compared between laparoscopic and open groups in unmatched and matched analyses.

RESULTS

During the 7-year study period, 343 distal pancreatectomies were performed; 107 (31%) were attempted laparoscopically and 236 (69%) were performed open. The conversion rate was 30%. Laparoscopic patients were younger (median 60 vs 64 years, p < 0.0001), experienced less blood loss (median 150 vs 350 mL, p < 0.0001), longer operative times (median 163 vs 194 minutes, p < 0.0001), shorter hospital stay (median 5 vs 7 days, p < 0.0001), and had fewer postoperative complications (27% vs 40%, p = 0.03) than open patients. The rates of complications of grade 3 or greater (20% vs 20%, p = NS) and pancreatic leak (15% vs 13%, p = NS) were similar between laparoscopic and open groups. Patients having procedures that were converted had a higher body mass index (BMI) than patients who did not (28 vs 25, p = 0.035). Patients with converted resections experienced higher rates of complications of grade 3 or greater (36% vs 20%, p = 0.008) and pancreatic leaks (27% vs 13%, p = 0.03) than open patients. Compared with matched open patients, laparoscopic patients had longer operative times (195 minutes vs 160 minutes, p < 0.0001), less blood loss (175 mL vs 300 mL, p < 0.0001), and shorter hospital stay (5 days vs 6 days, p < 0.001).

CONCLUSIONS

Patients who had laparoscopic distal pancreatectomy experienced decreased blood loss and a shorter hospital stay compared with matched patients undergoing open resection. Careful patient selection is important because patients who required conversion experienced higher rates of complications and pancreatic leak.

Preoperative endoscopic tattooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy

BACKGROUND

Precise and expedient localization of small pancreatic tumors during laparoscopic distal pancreatectomy can be difficult owing to the decreased tactile ability of laparoscopy and the homogenous appearance of the surrounding retroperitoneal fat. Precise localization of the lesion is critical to achieving adequate margins of resection while preserving as much healthy pancreas as possible. The objective in this study was to determine the effect of endoscopic tattooing of the distal pancreas on operative time.

METHODS

We reviewed retrospectively 36 consecutive patients who had a laparoscopic distal pancreatectomy at our institution over a 4-year period (2006-2009). Ten patients underwent preoperative tattooing via an endoscopic transgastric technique using ultrasound guidance. The tattoo was performed using 2-4 cc of sterile purified carbon particles injected immediately proximal and anterior to the pancreatic lesion. Operative times were compared according to the presence of a tattoo.

RESULTS

The endoscopically placed tattoo was easily visible upon entering the lesser sac in all 10 patients at laparoscopy. Patients with a tattoo had a shorter operative time (median, 128.5 minutes; range, 53-180) compared with patients without a tattoo (median, 180 minutes; range, 120-240; P < .01). None of the tattoo group required repeat surgery, whereas 1 patient who was not tattooed required re-resection for a lesion missed in the initial specimen. There were no complications associated with the endoscopic ultrasound-guided tattoo.

CONCLUSION

Endoscopic ultrasound-guided tattooing of pancreas lesions before a laparoscopic distal pancreatectomy is safe and is associated with decreased operative time compared with nontattooed patients. This technique can allow for quick and precise localization of the lesion, allowing for optimal preservation of pancreas parenchyma and demarcating an appropriate line of resection.

Laparoscopic surgery for pancreatic tumors

The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.

Should all distal pancreatectomies be performed laparoscopically?

Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.

Systematic review of minimally invasive pancreatic resection

BACKGROUND

Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas.

METHODS

An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed.

RESULTS

Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased.

CONCLUSIONS

Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.

Distal pancreatectomy: what is the standard for laparoscopic surgery?

BACKGROUND/AIMS

Distal pancreatectomy (DP) is performed for a range of benign and malignant lesions. Accurate pre-operative diagnosis can be unreliable and morbidity remains high. This study evaluates a 12-year, single-centre experience with open DP to review indications, diagnoses and associated morbidity.

METHODS

Retrospective review of patients who underwent DP at a UK-based tertiary referral centre between 1994 and 2006.

RESULTS

Sixty-five patients (mean age 49.9 years) had final diagnoses of chronic pancreatitis +/- pseudocyst (n= 22), benign cystadenoma (n= 15), neuroendocrine tumour (n= 8), primary pancreatic carcinoma (n= 6) and 14 other conditions. DP performed for presumed cystic neoplasm (n= 24) revealed a correct pre-operative diagnosis in 71% of patients. Histological examination confirmed that 59% of resected cystic tumours were either malignant or had malignant potential. When DP was undertaken for presumed pseudocyst (n= 12), 83% of cases were correctly diagnosed pre-operatively. Overall mortality and morbidity rates were 3% and 39%, respectively, with five patients (8%) developing a clinically significant pancreatic fistula. Ten (17%) patients developed diabetes mellitus and nine (14%) required long-term pancreatic exocrine supplementation.

CONCLUSIONS

Open DP can be performed with acceptable morbidity, low mortality and preservation of pancreatic function in the majority of cases, setting the standard for laparoscopic techniques.

Laparoscopic pancreatic resection for cancer

Laparoscopic (lap) organ resection is now commonly performed for the management of solid tumors of the kidney, colon, adrenal glands and prostate. Surgeons have been slower to adopt minimally invasive approaches to the pancreas owing to operative complexity and complication potential. The majority of existing reports concerning lap pancreatectomy are single-center studies that describe experience with fewer than 20 cases. Only recently have larger experiences surfaced demonstrating the safety and efficacy of lap tumor enucleation and lap left pancreatectomy. As neoplastic disease is the most common indication for pancreatic resection, understanding the effects of the lap approach to pancreatectomy on cancer outcome is crucial. In addition to concerns of port-site tumor recurrence and tumor dissemination due to lap manipulation in the setting of pneumoperitoneum, adequacy of resection as defined by margin status and nodal assessment must be considered. This review covers the development and current state-of-the-art of lap pancreatic surgery for cancer. Existing data are reviewed for both open and lap pancreatic resections, with particular attention to pancreatic ductal adenocarcinoma. Projections of future advances in the field of lap pancreatic surgery are provided.

Systematic review of minimally invasive pancreatic resection

BACKGROUND

Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas.

METHODS

An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed.

RESULTS

Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased.

CONCLUSIONS

Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.

Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches

OBJECTIVES

To compare perioperative outcomes of laparoscopic left-sided pancreatectomy (LLP) with traditional open left-sided pancreatectomy (OLP) in a multicenter experience.

SUMMARY AND BACKGROUND DATA

LLP is being performed more commonly with limited data comparing results with outcomes from OLP.

METHODS

Data from 8 centers were combined for all cases performed between 2002-2006. OLP and LLP cohorts were matched by age, American Society of Anesthesiologists, resected pancreas length, tumor size, and diagnosis. Multivariate analysis was performed using binary logistic regression.

RESULTS

Six hundred sixty-seven LPs were performed, with 159 (24%) attempted laparoscopically. Indications were solid lesion in 307 (46%), cystic in 295 (44%), and pancreatitis in 65 (10%) cases. Positive margins occurred in 51 (8%) cases, 335 (50%) had complications, and significant leaks occurred in 108 (16%). Conversion to OLP occurred in 20 (13%) of the LLPs. In the matched comparison, 200 OLPs were compared with 142 LLPs. There were no differences in positive margin rates (8% vs. 7%, P = 0.8), operative times (216 vs. 230 minutes, P = 0.3), or leak rates (18% vs. 11%, P = 0.1). LLP patients had lower average blood loss (357 vs. 588 mL, P < 0.01), fewer complications (40% vs. 57%, P < 0.01), and shorter hospital stays (5.9 vs. 9.0 days, P < 0.01). By MVA, LLP was an independent factor for shorter hospital stay (P < 0.01, odds ratio 0.33, 95% confidence interval 0.19-0.56).

CONCLUSIONS

In selected patients, LLP is associated with less morbidity and shorter LOS than OLP. Pancreatic fistula rates are similar for OLP and LLP. LLP is appropriate for selected patients with left-sided pancreatic pathology.

Laparoscopic and Hand-Assisted Distal Pancreatectomy

With the increased use of CT, discovering incidental pancreatic lesions has become commonplace. Lesions in the distal pancreas lend themselves well to laparoscopic resection. We reviewed our experience with laparoscopic distal pancreatectomy. During the study period, 32 distal pancreatectomies were performed. There were 20 females. Mean patient age was 58.0 years (range, 23–83 years) and mean body mass index was 29.9 kg/m2 (range, 19.9–44.7 kg/m2). Technique was laparoscopic (25) or hand-assisted (seven) with one conversion in each group. The spleen was preserved in six patients (18.8%). Mean operative time overall was 238 minutes (range, 140–515 minutes); hand-assisted was 222 minutes and laparoscopic was 254 minutes. Estimated blood loss averaged 221 mL (range, 50–1800 mL). Mean tumor size was 2.7 cm (range, 0.6–7 cm). Tumor pathology was serous cystadenoma (10), neuroendocrine tumor (six), mucinous cystic neoplasm (four), intrapapillary mucinous neoplasm (four), adenocarcinoma (three), other (four), and solid pseudopapillary neoplasm (one). Mean length of stay was 5 days (range, 3–11 days). Complications were pancreatic fistula (six), wound infection (two), pulmonary embolism (one), pancreatitis (one), myocardial infarction (one), postoperative bleed from combined laparoscopic bilateral oophorectomy (one), and pancreatic stump staple line bleed requiring reoperation (one). There were no perioperative deaths. All pancreatic fistulas resolved with conservative management.

Laparoscopic pancreatic resection: the past, present, and future

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.

Staple line reinforcement reduces postoperative pancreatic stump leak after distal pancreatectomy

Pancreatic stump leak is the major source of morbidity after stapled distal pancreatectomy. We hypothesized that reinforcement of the stapler system with a buttress mat can improve leak rates when compared to standard stapling alone. We performed 13 consecutive distal pancreatectomies using our reinforced stapler system, forming our experimental group. A historical control group was composed of 18 patients undergoing stapled pancreatic closure without reinforcement. The main outcome measure was pancreatic leak in the postoperative period. Pancreatic leaks included fistulas and fluid collections (sterile or infected). Hospital length of stay was recorded as a secondary measure. Postoperative pancreatic leak rate was zero in the experimental group, but 39% in the control group (P = 0.025). Development of a pancreatic leak resulted in prolonged hospital stays: 13.6 vs 8.3 days (P < 0.03). We conclude that staple line reinforcement is a simple and effective method of reducing pancreatic stump leakage after distal pancreatectomy. The economic impact of lower leak rates is reflected in significantly shorter hospital stays. The results of our study should be validated in a randomized controlled trial.

Laparoscopic distal pancreatectomy with splenic preservation for serous cystadenoma: a case report and literature review

A minimally invasive approach can be beneficial in a spleen-preserving distal pancreatectomy. This article reports a 71-year-old woman who presented to her internist with hypertension and persistent hypokalemia. A computed tomography scan to rule out a functional adrenal mass incidentally revealed a 4 cm x 3 cm x 2 cm serous cystadenoma of the distal pancreas and normal adrenal glands. The patient was referred to the general surgery service for resection of the distal pancreatic lesion. A laparoscopic spleen-preserving distal pancreatectomy was performed. The lesion was completely excised, and the pathology revealed serous cystadenoma with focal fibrosis and atrophic acini. The postoperative advantages of this approach were the early return of bowel function, minimal narcotic requirements, and early resumption of normal activities. This case illustrates the advantages of minimally invasive surgery in the performance of a spleen-preserving distal pancreatectomy.