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Kauffmann et al. Mini-invasive Surg 2020;4:54 I http://dx.doi.org/10.20517/2574-1225.2020.46 Page 7 of 10

Our series confirms that RA-SPDP is feasible in most patients, when selected appropriately, with a high
probability of spleen preservation and a low incidence of severe complications. Admittedly, we have
[29]
approximately 20 years of experience in minimally invasive distal pancreatectomy , we have performed
approximately 400 robotic pancreatectomies, and we treat hundreds of new patients each year with surgical
diseases of the pancreas and the periampullary region.

While robotic assistance is certainly associated with increased costs and longer operative times [30-32] , there
is no doubt that the use of da Vinci Surgical System enhances surgeon’s ability to preserve the spleen
during distal pancreatectomy [33,34] . In this respect we believe that the robot is particularly useful when the
Kimura technique is adopted as it allows safe dissection and preservation of splenic vessels. Although the
Warshaw procedure can be considered when the splenic vessels cannot be preserved, the overall results of
[35]
this operation are inferior to those of the Kimura procedure making preservation of the splenic vessels
preferable, whenever feasible. In this respect our experience is quite unique as we had never to adopt the
Warshaw procedure, that was instead adopted in 28% to 50% of the patients in other robotic series [36,37] .

We have previously reported that in our hands the risk of unintentional resection of a serous cystadenoma
[38]
not causing symptoms was 2.1% .
We wish here to underscore that asymptomatic patients with a known diagnosis of serous cystadenoma
should not undergo resection regardless of the size of the tumor. We wish also to emphasize that availability
of robotic technology and ability to perform a minimally invasive procedure sparing the spleen is not a
reason to expand indications to resection. The seemingly high rate of resected serous cystadenomas should
therefore be read in the light of the high selection applied to patients reported herein to include only
patients with presumably benign tumors. If the same figures were put in the context of our general activity,
the rate of resected serous cystadenomas would not exceed 5%.

Our results underscore the importance of patients’ selection, not only from the perspective of spleen
preservation but also, and perhaps even more importantly, because of the risk of missed malignancy. In our
series we found that tumors initially thought to be pre-malignant were instead already overtly malignant
in 7 patients (13.2%). Some of these tumors were either in situ or low-grade, so that RA-SPDP could be
adequate anyway. On the other hand, we had a case of invasive pancreaticobiliary IPMN and four cases
of neuroendocrine carcinoma with lymph nodes metastasis. In these patients the oncologic issue is not to
have left the spleen behind, but having spared the splenic vessels and, possibly, having not performed an
adequate lymphadenectomy. Indeed, spleen preservation, but using the Warshaw technique, was recently
proposed even for pancreatic cancer considering that lymph node metastasis in the splenic hilum are
[39]
exceedingly rare . Sparing the splenic vessels, instead, could leave behind microscopic tumor residual (R1
resection). Although this was not the case in our series, even at the level of vascular beds, the risk is real.
Our policy of systematic lymph node clearance around splenic vessels permitted to have a clearer picture of
the tumor stage, so that we could decide how to manage these cases based on sound data. However, if the
malignant tumor is in the body of the pancreas, several lymph node stations are not cleared (such as station
number 9) that could harbor metastatic lymph nodes.

In this series we have rarely employed a stapler to divide the pancreas. We have rather preferred to divide
the gland sharply while identifying and ligating selectively the pancreatic duct. There is no agreement on
[1]
the ideal technique for pancreatic transection and closure during distal pancreatectomy . During the first
part of our experience, after sharp division of the pancreas the duct was selectively ligated, and the stump
closed with interrupted sutures. Later, thanks to the availability of robotized laparoscopic staplers (namely
the Signia power handle and the iDrive - Minneapolis, Medtronic, Covidien) we converted to the use
TM
TM
of these devices. The stapler was handled and fired by the assistant at the table. The size of the cartridge