Total Laparoscopic Distal Pancreatectomy: Beyond Selected Patients

Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS (P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.