True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation

Outcomes of robotic versus laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Minimally invasive ventral mesh rectopexy is considered the standard of care in the surgical management of rectal prolapse syndromes in fit patients. We aimed to investigate the outcomes after robotic ventral mesh rectopexy (RVR) and compare them with our laparoscopic series (LVR). Additionally, we report the learning curve of RVR. As the financial aspect for the use of a robotic platform remains an important obstacle to allow generalized adoption, cost-effectiveness was also evaluated.

PATIENTS AND METHODS

A prospectively maintained data set including 149 consecutive patients who underwent a minimally invasive ventral rectopexy between December 2015 and April 2021 was reviewed. The results after a median follow-up of 32 months were analyzed. Additionally, a thorough assessment of the economic aspect was performed.

RESULTS

On a total of 149 consecutive patients 72 underwent a LVR and 77 underwent a RVR. Median operative time was comparable for both groups (98 min (RVR) vs. 89 min (LVR); p = 0.16). Learning curve showed that an experienced colorectal surgeon required approximately 22 cases in stabilizing the operative time for RVR. Overall functional results were similar in both groups. There were no conversions or mortality. There was, however, a significant difference (p < 0.01) in hospital stay in favor of the robotic group (1 day vs. 2 days). The overall cost of RVR was higher than LVR.

CONCLUSIONS

This retrospective study shows that RVR is a safe and feasible alternative for LVR. With specific adjustments in surgical technique and robotic materials, we developed a cost-effective way of performing RVR.

"Parenchyma transection-first" strategy is superior to "tunnel-first" strategy in robotic spleen-preserving distal pancreatectomy with conservation of splenic vessels

BACKGROUND

Creating a tunnel between the pancreas and splenic vessels followed by pancreatic parenchyma transection ("tunnel-first" strategy) has long been used in spleen-preserving distal pancreatectomy (SPDP) with splenic vessel preservation (Kimura's procedure). However, the operation space is limited in the tunnel, leading to the risks of bleeding and difficulties in suturing. We adopted the pancreatic "parenchyma transection-first" strategy to optimize Kimura's procedure.

METHODS

The clinical data of consecutive patients who underwent robotic SPDP with Kimura's procedure between January 2017 and September 2022 at our center were retrieved. The cohort was classified into a "parenchyma transection-first" strategy (P-F) group and a "tunnel-first" strategy (T-F) group and analyzed.

RESULTS

A total of 91 patients were enrolled in this cohort, with 49 in the T-F group and 42 in the P-F group. Compared with the T-F group, the P-F group had significantly shorter operative time (146.1 ± 39.2 min vs. 174.9 ± 46.6 min, P < 0.01) and lower estimated blood loss [40.0 (20.0-55.0) mL vs. 50.0 (20.0-100.0) mL, P = 0.03]. Failure of splenic vessel preservation occurred in 10.2% patients in the T-F group and 2.4% in the P-F group (P = 0.14). The grade 3/4 complications were similar between the two groups (P = 0.57). No differences in postoperative pancreatic fistula, abdominal infection or hemorrhage were observed between the two groups.

CONCLUSIONS

The pancreatic "parenchyma transection-first" strategy is safe and feasible compared with traditional "tunnel-first strategy" in SPDP with Kimura's procedure.

Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study

Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 ± 1.8 vs. 6.3 ± 1.5 days, p = 0.019; double 8.5 ± 3.8 vs. 6.6 ± 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 ± 78.7 vs. 227.5 ± 54.7 min, p = 0.018; double 448.0 ± 85.6 vs. 341.2 ± 43.1 min, p = 0.008), flap ischemia time (53.6 ± 15.1 vs. 40.9 ± 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon's skills as well as the overall experience of the medical institution.

Robotische Pankreaschirurgie – Lernkurve und Etablierung

Minimalinvasive Resektionstechniken zur Behandlung verschiedener Pathologien des Pankreas sind potenziell vorteilhaft für die behandelten Patienten in Bezug auf Rekonvaleszenzzeit und postoperative Morbidität, stellen jedoch eine besondere technische Herausforderung für den behandelnden Chirurgen dar. Der Einzug der robotischen Technik in die Viszeralchirurgie bietet eine prinzipielle Möglichkeit zur weitreichenden Verbreitung minimalinvasiver Verfahren in der Pankreaschirurgie.

Ziel dieser Arbeit war es, die Entwicklungsmöglichkeiten der robotischen Pankreaschirurgie in Deutschland zu überprüfen. Datengrundlage sind die Qualitätsberichte der Krankenhäuser der Jahre 2015–2019 kombiniert mit einer selektiven Literaturrecherche.

Die Anzahl der vorliegenden Qualitätsberichte reduzierte sich von 2015 bis 2019 von 1635 auf 1594. Im Median führten 96 Kliniken 11–20, 56 Kliniken 21–50 und 15 Kliniken mehr als 50 Pankreaskopfresektionen jährlich durch. Bei den Linksresektionen waren es 35 Kliniken mit 11–20, 14 Kliniken mit 21–50 und 2 Kliniken mit mehr als 50 Eingriffen. Unter Berücksichtigung aller Kliniken, die 5 oder mehr Linksresektionen pro Jahr durchführen, wurden an nur 29 Kliniken minimalinvasive Verfahren eingesetzt. Der Anteil an laparoskopischen Linksresektionen über 50% wurde an nur 7 Kliniken beschrieben.

Nach Datenlage in der Literatur divergieren die Lernkurven für die robotische Pankreaslinks- und Pankreaskopfresektion. Während die Lernkurve für die robotische Pankreaslinksresektion nach etwa 20 Eingriffen durchlaufen ist, hat die Lernkurve für die robotische Pankreaskopfresektion mehrere Plateaus, die etwa nach 30, 100 und 250 Eingriffen erreicht werden.

Aufgrund der dezentralen Struktur der Pankreaschirurgie in Deutschland scheint ein flächendeckendes Angebot robotischer Verfahren aktuell in weiter Ferne. Insbesondere die Etablierung der robotischen Pankreaskopfresektion wird zunächst Zentren mit entsprechend hoher Fallzahl vorbehalten bleiben.

Learning curves in minimally invasive pancreatic surgery: a systematic review

Background

The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery.

Methods

A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included.

Results

In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10–30) and 23.5 cases (7–40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4–60) and 36.5 cases (20–80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon’s experience and patient’s demographic.

Conclusions

There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.

Short-Term Outcomes of the Tail-First Approach in Laparoscopic Spleen-Preserving Distal Pancreatectomy: a Single Center Experience

BACKGROUND

Several approaches have been reported during laparoscopic spleen-preserving distal pancreatectomy (LSPDP), such as medial, lateral, and posterior approaches. This study reports a tail-first approach that is mobilization of the pancreatic gland from tail to neck followed by division. The short-term outcomes are described.

METHODS

Cases which underwent LSPDP from 2014 to 2020 at Qilu Hospital of Shandong University were included. Clinical parameters were collected and analyzed.

RESULTS

One hundred five cases were collected, including 54 Kimura, 45 Warshaw, and 6 modified-Warshaw procedures. Seventy-seven patients (73.3%) underwent LSPDP by a tail-first approach (TFA-LSPDP) and 28 (26.7%) by a medial approach (M-LSPDP). Compared with the M-LSPDP, the TFA-LSPDP group had a lower incidence of splenic infraction (9.1 VS 25.0%, P = 0.05) and a higher frequency of Kimura procedure (55.8 VS 39.3%, P = 0.053).

CONCLUSION

TFA-LSPDP is feasible and safe for treatment of benign and low malignant lesions of the distal pancreas, which has a lower incidence of splenic infraction and a higher frequency of splenic vessel preservation compared with the traditional medial approach.

The use of selective splenic vascular control in laparoscopic splenic vessels and spleen preservation distal pancreatectomy

Background

In the process of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvSPDP), because the splenic blood vessels have many small branches, how to safely separate the splenic blood vessels from the pancreas has always been the focus and difficulty of this operation. Many cases were switched to laparotomy, or the Warshaw method due to the inability to control bleeding during the separation of the splenic blood vessels. Therefore, we tried to use the selective splenic vascular control method when separating the splenic blood vessels to observe its effect on the conditions of the surgical patients during and after the operation.

Methods

We retrospectively collected 35 cases of LsvSPDP conducted in our center from September 2015 to December 2020, including 5 males and 30 females. Considering the influence of the surgical learning curve, the cases were divided into three groups. Finally, through statistics of its intraoperative and postoperative conditions, the effectiveness of selective splenic vascular control method can be judged.

Results

Patients in Group 2 and 3 showed significantly less blood loss (172.5 and 134.44 mL, respectively) compared to patients in Group 1 (541.43 mL; P=0.01). However, the amount of blood loss was not significantly different between Group 2 and 3.

Conclusions

The amount of bleeding was significantly reduced by splenic blood vessel control technology. And it can improve the success rate of spleen preservation, preserve the success rate of splenic blood vessels, and reduce intraoperative bleeding.

Procedure-specific Training for Robot-assisted Distal Pancreatectomy

OBJECTIVE

To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality.

BACKGROUND

RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce.

METHODS

A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy.

RESULTS

After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP.

CONCLUSION

Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Implementation and training with laparoscopic distal pancreatectomy: 23-year experience from a high-volume center

Background

Distal pancreatectomy is the most common procedure in minimally-invasive pancreatic surgery. Data in the literature suggest that the learning curve flattens after performing up to 30 procedures. However, the exact number remains unclear.

Methods

The implementation and training with laparoscopic distal pancreatectomy (LDP) in a high-volume center were studied between 1997 and 2020. Perioperative outcomes and factors related to conversion were assessed. The individual experiences of four different surgeons (pioneer and adopters) performing LDP on a regular basis were examined.

Results

Six hundred forty LDPs were done accounting for 95% of all distal pancreatectomies performed throughout the study period. Conversion was needed in 14 (2.2%) patients due to intraoperative bleeding or tumor adherence to the major vasculature. Overall morbidity and mortality rates were 35 and 0.6%, respectively. Intra- and postoperative outcomes did not change for any of the surgeons within their first 40 cases. Operative time significantly decreased after the first 80 cases for the pioneer surgeon and did not change afterwards although the proportion of ductal adenocarcinoma increased. Tumor size increased after the first 80 cases for the first adopter without affecting the operative time.

Conclusions

In this nearly unselected cohort, no significant changes in surgical outcomes were observed throughout the first 40 LDPs for different surgeons. The exact number of procedures required to overcome the learning curve is difficult to determine as it seems to depend on patient selection policy and specifics of surgical training at the corresponding center.

Supplementary Information

The online version of this article (10.1007/s00464-021-08306-3) contains supplementary material, which is available to authorized users.

Learning curve of laparoscopic and robotic pancreas resections: a systematic review

BACKGROUND

Minimally invasive pancreatic resection has been shown recently in some randomized trials to be superior in selected perioperative outcomes compared with open resection when performed by experienced surgeons. However, minimally invasive pancreatic resection is associated with a long learning curve. This study aims to summarize the current evidence on the learning curve of minimally invasive pancreatic resection and define the number of cases required to surmount the learning curve.

METHODS

A systematic search was performed on PubMed, Embase, Scopus, and the Cochrane database using a detailed search strategy. Studies that did not describe the learning curve were excluded from the study. Data on the method of learning curve analysis, single surgeon versus institutional learning curve, and outcome measures were extracted and analyzed.

RESULTS

A total of 32 studies were included in the pooled analysis: 12 on laparoscopic pancreatoduodenectomy, 9 on robotic pancreatoduodenectomy, 12 on laparoscopic distal pancreatectomy, and 3 on robotic distal pancreatectomy. Sample population was comparable between laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy (median 63 vs 65). Six of 12 studies and 7 of 9 studies used nonarbitrary methods of analysis in laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy, respectively. Operating time was used as the single outcome measure in 4 of 12 studies in laparoscopic pancreatoduodenectomy and 5 of 9 studies in robotic pancreatoduodenectomy. Overall, there was no significant difference between the number of cases required to surmount the learning curve for laparoscopic pancreatoduodenectomy versus robotic pancreatoduodenectomy (laparoscopic pancreatoduodenectomy 34.1 [95% confidence interval 30.7-37.7] versus robotic pancreatoduodenectomy 36.7 [95% confidence interval 32.9-41.0]; P = .8241) and laparoscopic distal pancreatectomy versus robotic distal pancreatectomy (laparoscopic distal pancreatectomy 25.3 [95% confidence interval 22.5-28.3] versus robotic distal pancreatectomy 20.7 [95% confidence interval 15.8-26.5]; P = .5997.) CONCLUSION: This study provides a detailed summary of existing evidence around the learning curve in minimally invasive pancreatic resection. There was no significant difference between the learning curve for robotic pancreatoduodenectomy versus laparoscopic pancreatoduodenectomy and robotic distal pancreatectomy versus laparoscopic distal pancreatectomy. These findings were limited by the retrospective nature and heterogeneity of the studies published to date.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

"Kimura-first" strategy for robotic spleen-preserving distal pancreatectomy: experiences from 61 consecutive cases in a single institution

Background

Robotic spleen-preserving distal pancreatectomy (RSPDP) is an ideal procedure for benign and low-grade malignant tumors in the distal pancreas, and two splenic preservation techniques (the Kimura and Warshaw techniques) can be used for RSPDP. This study aimed to evaluate the feasibility and safety of the "Kimura-first" strategy for RSPDP and to investigate the risk factors affecting the preservation of the spleen and splenic vessels.

Methods

The electronic medical records of patients who underwent robotic distal pancreatectomy (RDP) between October 2016 and December 2019 at our institution were retrospectively reviewed. Univariate and multivariate analyses were conducted to identify the risk factors influencing preservation of the spleen and splenic vessels during RDP.

Results

Sixty-one patients scheduled for RSPDP who received RDP were included in this study [Kimura technique, 41 patients; Warshaw technique, 11 patients; and robotic distal pancreatectomy with splenectomy (RDPS), 9 patients]. The overall splenic preservation rate with RDP was 85.2% (52/61). The preservation rate of splenic vessels with the Kimura technique with RSPDP was 78.8% (41/52). The RSPDP group had remarkably less estimated blood loss (EBL; median 50 vs. 300 mL, P=0.000) and a lower morbidity rate (13.5% vs. 44.4%, P=0.047) than the RDPS group. The logistic regression models showed that obvious splenic vessel compression by the tumor was an independent risk factor for splenic vessel preservation with RSPDP (OR 0.021, 95% CI: 0.002-0.271, P=0.003) and RDP (OR 0.019, 95% CI: 0.002-0.176, P=0.000).

Conclusions

The "Kimura-first" strategy is feasible and safe for RSPDP, with high rates of splenic and splenic vessel preservation. Obvious splenic vessel compression by the tumor can be used as a predictor of splenic vessel preservation with planned RDP.

Application of a preoperative image scoring system in laparoscopic spleen-preserving distal pancreatectomy

BACKGROUND

A reasonable surgical plan is crucial to laparoscopic spleen-preserving distal pancreatectomy. This study proposed a preoperative image classification and scoring system, then evaluated the predictive value in creating a spleen-preserving strategy.

METHODS

Data for patients who underwent laparoscopic spleen-preserving distal pancreatectomy at our hospital were collected from a prospective database. Clinical parameters and preoperative images were reviewed and analysed.

RESULTS

We included 58 cases, and patients underwent the Kimura procedure (n = 29) or the Warshaw procedure (n = 29). According to the relationship between the tumour and the splenic vein in preoperative images, we proposed an image classification constituting four types. In the univariate analysis, age, tumour size, length of the distal pancreas to the left of the tumour and the image classification were significantly associated with spleen-preservation methods. Multivariate analysis indicated that tumour size and image classifications were independent factors. We established a scoring system by combining these two factors and scored and classified patients into four groups as 0, 61, 100 and 161 points. The probabilities of spleen-preservation procedures corresponding to different points were then calculated.

CONCLUSION

This preoperative image classification and scoring system might be helpful when creating a spleen-preserving strategy during laparoscopic distal pancreatectomy.

Laparoscopic Splenic Vessels and Spleen Preservation Distal Pancreatectomy Via Inferior-Posterior Splenic Vein Approach

BACKGROUND

Preservation of splenic vessels can minimize the risks of splenic infarction and gastric varices in laparoscopic spleen preserving distal pancreatectomy. A well-established procedure would provide high splenic vessels and spleen preservation rate. This study evaluated the outcomes and depending factors of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvspDP) via inferior-posterior splenic vein approach.

MATERIALS AND METHODS

This retrospective study enrolled patients who underwent LsvspDP via inferior-posterior splenic vein approach in National Cheng-Kung University Hospital from February 2009 to June 2019. The clinic-pathologic data were collected and analyzed. The primary outcome of this study was the learning curve based on the cumulative sum analysis. The secondary outcomes were to evaluate the critical factors for the failure of splenic vessels and spleen preservation.

RESULTS

During the study period, a total of 64 patients received LsvspDP attempt. Splenic vessels were successfully preserved in 49 patients and the overall spleen preservation rate was 76.6%. According to cumulative sum analysis, the learning curve of LsvspDP was the 33rd case and several plateaus were observed during the learning curve phase. Old age (P=0.001), tail location (P=0.038), and large tumor (P=0.01) were independent risk factors of failed splenic vessels preservation, whereas the cut-off point of tumor size for prediction of spleen preservation was 5.4 cm. The complication rates were 7.8%, 7.8%, and 12.5% for Clavien grade I, II, and III, respectively, and 0% for Clavien grade IV or V. The rate of postoperative pancreatic fistula-grade B was 14.8%, among which the tail location was lower than the nontail location (0% vs. 24.3%; P=0.008). The mean value of operative time, blood loss, and hospital stay were 198±67 minutes, 139±242 mL, and 8.5±5.6 days, respectively.

CONCLUSIONS

In LsvspDP, the inferior-posterior splenic vein approach resulted in high splenic vessels and spleen preservation rate. Thirty-three patients were required to overcome the learning curve. Old age, tail location, and large tumor size were independent factors for the failure of splenic vessels preservation, whereas the cut-off value for tumor size was 5.4 cm to predict splenic vessels preservation.

Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach

Background

This study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP).

Methods

Between November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared.

Results

The robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428).

Conclusions

The present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.

Warshaw Technique in Laparoscopic Spleen-Preserving Distal Pancreatectomy: Surgical Strategy and Late Outcomes of Splenic Preservation

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either the preservation or the resection of splenic vessels; the latter is also known as Warshaw technique. Our study is designed to investigate the operation selection strategy when proceeding LSPDP and to evaluate the long-term outcomes of patients undergoing Warshaw surgery. The medical records and follow-up data of patients who underwent LSPDP in Qilu Hospital, Shandong University, were reviewed retrospectively. A total of thirty-five patients were involved in this study, including 17 cases of patients who were treated with Warshaw procedure (WT) while the other 18 cases had splenic vessels preserved (SVP). Compared with the SVP group, the operative time and intraoperative blood loss in WT group were improved significantly. The incidence of early postoperative splenic infarction was higher in WT group. However, there was no report of splenic abscess or second operation. Follow-up data confirmed that there was no significant difference in spleen phagocytosis and immune function compared with normal healthy population. Our study confirms that LSPDP-Warshaw procedure is a safe and efficient treatment for the benign or low grade malignant tumors in distal pancreas in selected patients. The long-term spleen function is normal after Warshaw procedure. Preoperative assessment and intraoperative exploration are recommended for the selection of operation approaches.

Precision Technique for Splenectomy Limits Mouse Stress Responses for Accurate and Realistic Measurements for Investigating Inflammation and Immunity

Splenectomy in an animal model requires a standardized technique utilizing best practice to avoid variability which can result in adverse impact to the animal resulting in flawed physiologic responses simply due to technique rather than to the studied variables. In the case of the spleen, often investigators are analyzing the animal immune or inflammatory responses. Surgical splenectomy involves many variables from the training and expertise of the surgeon, which directly correlates to surgical technique to the length of operation and ease of the procedure. This operation, in turn, impacts blood loss and insensible fluid losses, sterile technique, unintended trauma to the spleen and surrounding organs, the length of the incision and the duration of the operation with more prolonged exposure to anesthetic agents. All these variables ultimately play a significant role in the experiment since they directly affect the response of the model in terms of inflammation, immune activation, or even suppression. Undesired variables such as these go unnoticed and lead to inaccurate and misleading data.