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Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4 years and 31.4 kg/m2, respectively. The mean total operative time was 323 min. The estimated mean blood loss was 240 ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6 days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve. [ABSTRACT FROM AUTHOR]

Background: Robotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP).Methods: Between March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group.Results: The two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group.Conclusion: Apart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS. [ABSTRACT FROM AUTHOR]

Purpose/aim: Spleen preservation distal pancreatectomy (SPDP) can be achieved by either splenic vessel preservation distal pancreatectomy (SVP-DP) or Warshaw technique (WT). Although studies comparing SVP-DP with WT have been reported, controversies exist. The aim of our study is to assess and compare the safety and feasibility of SVP-DP and WT. Materials and methods: Two authors searched the online database independently till April 30, 2017. Data extraction and quality assessment were performed independently by two authors. Short- and long-term outcomes of WT and SVP-DP were evaluated. Subgroup analysis was performed on laparoscopic surgery. Odds ratios (OR) with 95% confidence interval (CI) and mean difference (MD) with 95% CI were estimated. Results: A total of 664 patients from 11 retrospective cohort studies were included. Meta-analysis showed the WT group had a significantly higher incidence of splenic infarction (OR = 0.12; 95% CI: 0.07–0.20; p < 0.00001) and gastric/epigastric varices (OR = 0.11; 95% CI: 0.05–0.24; p < 0.00001). And more patients suffering from splenic infarction from WT group needed further splenectomy (OR = 0.13; 95% CI: 0.02–0.84; p = 0.03). While there was no difference between the two procedures in terms of pancreatic fistula (OR = 0.55; 95% CI: 0.25–1.19; p = 0.13), overall morbidity (OR = 0.87; 95% CI: 0.59–1.30; p = 0.50) and hospital stay (MD = −0.45; 95% CI: −1.73-0.82; p = 0.49). Conclusions: Due to relatively higher risk of postoperative splenic infarction, gastric/epigastric varices and Clavien–Dindo III–V complications, WT is not as safe as SVP-DP. However, well-conducted randomized clinical trials are still needed due to the limitations of current studies.

Purpose/aim: Spleen preservation distal pancreatectomy (SPDP) can be achieved by either splenic vessel preservation distal pancreatectomy (SVP-DP) or Warshaw technique (WT). Although studies comparing SVP-DP with WT have been reported, controversies exist. The aim of our study is to assess and compare the safety and feasibility of SVP-DP and WT. Materials and methods: Two authors searched the online database independently till April 30, 2017. Data extraction and quality assessment were performed independently by two authors. Short- and long-term outcomes of WT and SVP-DP were evaluated. Subgroup analysis was performed on laparoscopic surgery. Odds ratios (OR) with 95% confidence interval (CI) and mean difference (MD) with 95% CI were estimated. Results: A total of 664 patients from 11 retrospective cohort studies were included. Meta-analysis showed the WT group had a significantly higher incidence of splenic infarction (OR = 0.12; 95% CI: 0.07–0.20; p < 0.00001) and gastric/epigastric varices (OR = 0.11; 95% CI: 0.05–0.24; p < 0.00001). And more patients suffering from splenic infarction from WT group needed further splenectomy (OR = 0.13; 95% CI: 0.02–0.84; p = 0.03). While there was no difference between the two procedures in terms of pancreatic fistula (OR = 0.55; 95% CI: 0.25–1.19; p = 0.13), overall morbidity (OR = 0.87; 95% CI: 0.59–1.30; p = 0.50) and hospital stay (MD = −0.45; 95% CI: −1.73-0.82; p = 0.49). Conclusions: Due to relatively higher risk of postoperative splenic infarction, gastric/epigastric varices and Clavien–Dindo III–V complications, WT is not as safe as SVP-DP. However, well-conducted randomized clinical trials are still needed due to the limitations of current studies. [ABSTRACT FROM AUTHOR]

There are numerous advantages of splenic vessel preservation in performing the minimally invasive spleen preserving distal pancreatectomy. Dissection along the splenic artery, and a medial to lateral dissection of the splenic vein, is associated with high risk of injury and bleeding. Proximal control of the splenic artery with vessel loops, which require tightening or adjustment with the advent of distal bleeding, is inefficient. Instead, a modified technique (the Royal North Shore Technique), whereby a vascular clamp is placed on the splenic artery, reduces splenic artery inflow and indirectly, splenic vein returns. This allows for more accurate and injury-free dissection of the now non-distended splenic vein and the associated tributaries, and maintains a relatively bloodless field in the event of arterial injury. [ABSTRACT FROM AUTHOR]

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., (Copyright © 2023 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Background: Vessel-preserving spleen preservation (SP) during distal pancreatectomy (DP) is supposed to be beneficial for patients with benign and borderline tumors. This study evaluated the first experiences with robotic-assisted laparoscopic DP (RA-LDP) and its rate of vessel preservation and SP compared to conventional laparoscopic DP (C-LDP). Methods: Patients scheduled for spleen-preserving DP for benign or borderline tumors by either C-LDP or RA-LDP were retrieved from a prospective database and retrospectively analyzed regarding vessel-preservation and SP, conversion rate, blood loss, operating time, complications, perioperative blood transfusion, postoperative hospital stay (PHS) and mortality. Results: Twenty-nine patients underwent C-LDP and 12 patients underwent RA-LDP between September 2009 and May 2015. SP rates were 79% (23 of 29) in the C-LDP and 92% (11 of 12) in the RA-LDP group (p = 0.32). Splenic vessels could be preserved in 17% (5 of 29) of the C-LDP and 50% (6 of 12) of the RA-LDP group (p = 0.052). Operating time, intraoperative blood loss, the number of perioperative red blood cell transfusions, overall morbidity and the rate of postoperative pancreatic fistulas were not different between the groups. PHS was shorter in the RA-LDP group (10.5 vs. 13 days; p = 0.02). Conclusion: RA-LDP for benign or borderline tumors of the pancreas is a safe procedure and tended to be associated with a better vessel-preservation rate, thereby making it a good alternative to C-LDP. [ABSTRACT FROM AUTHOR]

Background: Splenic preservation can be achieved through splenic vessel resection by Warshaw's technique (WT) or by preserving the splenic vessels. This meta-analysis aims to provide evidence-based comparison regarding the perioperative outcome and long-term benefits between patients with and without splenic vessel preservation (SVP) during spleen-preserving distal pancreatectomy. Method: A meta-analysis was performed to evaluate studies comparing splenic vessel preservation versus resection groups. Ten retrospective studies including 699 patients were eligible for an analysis of general, perioperative, and long-term outcomes. A further analysis composed of five subgroups was also conducted in terms of laparoscopic approach. Results: Warshaw's technique related to significant shorter operation time ( P < 0.0001). There was no difference in blood loss ( P = 0.45) as well as median tumor size ( p = 0.1) between the two groups. The overall rate of complications indicated no difference between SVP and WT ( P = 0.1), including pancreatic fistula rates, which were not statistically different among the treatment groups ( P = 0.27). However, the occurrence of gastric varices and splenic infarction was significant higher in the WT group ( P < 0.01). In laparoscopic subgroups, patients treated by WT had much lower blood loss ( P = 0.002). Conclusion: In spleen-preserving distal pancreatectomy, comparing with SVP, there is no evidence of significant benefit of WT. Nonetheless, surgeons should master both techniques and choose an appropriate one based on personal experience and a 'case by case' situation. However, the current available evidence is weak, and further randomized controlled data are warranted. [ABSTRACT FROM AUTHOR]

Background/objectives Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for low-grade malignant pancreas tumors was recently demonstrated. Although the procedure with splenic vessel preservation (SVP) is optimal for LSPDP, SVP is not always possible in patients with a large tumor or a tumor attached to splenic vessels. This study aimed to analyze the safety of two procedures: LSPDP without SVP, known as the Warshaw technique (lap-WT), and LSPDP with SVP (lap-SVP). Methods Seventeen patients who underwent a lap-WT and seven patients who underwent a lap-SVP were investigated retrospectively. Results The median follow-up duration was 45 (range 17–105) months. In the lap-WT and lap-SVP patients, the sizes of the tumors were 5 (1.3–12) and 1.5 (1–4) cm; the operative times were 304 (168–512) and 319 (238–387) min; the blood loss was 210 (5–3250) and 60 (9–210) gr; the length of the postoperative hospital stay was 15 (8–29) and 18 (5–24) days; the peak platelet counts were 37.2 (14.6–65.2) and 26.4 (18.8–41) × 10 4 /μL, and splenomegaly was observed in 10 (59%) and three (43%) patients, respectively. In both procedures, there was no local recurrence. In the lap-WT group, splenic infarctions were seen in four (24%) patients and perigastric varices were seen in two (12%) patients. All of these patients were observed conservatively. Conclusions Both the lap-WT and lap-SVP were found to be safe and effective, and in cases in which the tumor is relatively large or close to the splenic vessels, lap-WT can be used as the more appropriate procedure. [ABSTRACT FROM AUTHOR]

Background/objectives: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for low-grade malignant pancreas tumors was recently demonstrated. Although the procedure with splenic vessel preservation (SVP) is optimal for LSPDP, SVP is not always possible in patients with a large tumor or a tumor attached to splenic vessels. This study aimed to analyze the safety of two procedures: LSPDP without SVP, known as the Warshaw technique (lap-WT), and LSPDP with SVP (lap-SVP)., Methods: Seventeen patients who underwent a lap-WT and seven patients who underwent a lap-SVP were investigated retrospectively., Results: The median follow-up duration was 45 (range 17-105) months. In the lap-WT and lap-SVP patients, the sizes of the tumors were 5 (1.3-12) and 1.5 (1-4) cm; the operative times were 304 (168-512) and 319 (238-387) min; the blood loss was 210 (5-3250) and 60 (9-210) gr; the length of the postoperative hospital stay was 15 (8-29) and 18 (5-24) days; the peak platelet counts were 37.2 (14.6-65.2) and 26.4 (18.8-41) × 10(4)/μL, and splenomegaly was observed in 10 (59%) and three (43%) patients, respectively. In both procedures, there was no local recurrence. In the lap-WT group, splenic infarctions were seen in four (24%) patients and perigastric varices were seen in two (12%) patients. All of these patients were observed conservatively., Conclusions: Both the lap-WT and lap-SVP were found to be safe and effective, and in cases in which the tumor is relatively large or close to the splenic vessels, lap-WT can be used as the more appropriate procedure., (Copyright © 2014 IAP and EPC. Published by Elsevier B.V. All rights reserved.)