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Page 6 of 15 Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55

Figure 1. Trocars and hand-port placement in hand-assisted laparoscopic distal pancreatectomy. The placement of trocars widely
changed among different reports. Proposed placement of trocars: (A) hand-port; and (B) ports for trocars placement.

[85]
[86]
Dulucq et al. . Speicher et al. tracked the evolution of PD procedure over time at their institution,
observing a progressive increase in the use of TLS over LAPD with growing experience and a parallel
decrease of OT and complication rate; analogous findings were reported by Kim et al. and Lu et al. . The
[88]
[87]
literature appears rather inhomogeneous, and it is difficult to draw definitive conclusions; however, in light
of the reported data, the hybrid method appears to be safe and not inferior to the open approach [69,70,89,90] . It
also seems to provide some advantages over TLS in the early phase of the learning curve, but this may lose
relevance in the case of surgeons with extensive experience in laparoscopy. A relevant piece of literature
includes LAPD in the laparoscopic cases, and it is therefore difficult to extrapolate data on specific LAPD
outcomes. The current available literature on the topic is summarized in Table 2; articles where the surgical
technique is not specified were excluded. Placement of trocars and mini-laparotomy is shown in Figure 2.

MIS IN THE PANCREATIC SURGERY FIELD: WHERE ARE WE NOW?
Distal pancreatectomy
It is worth noting that, despite the initial setback, MIS has been greatly implemented in the pancreatic
surgery field in recent years. Several observational studies, reviews, and metanalysis reported on the safety of
minimally invasive distal pancreatectomy (MIDP) and proposed its advantages [98-106] . A multicentric
randomized controlled clinical trial comparing MIDP to open distal pancreatectomy demonstrated, despite
a similar major complication rate, a reduced rate of delayed gastric emptying, a reduced intraoperative
blood loss, a reduced time to functional recovery, and a better quality of life . In light of this evidence,
[107]
MIDP has become the standard of care for benign and low malignant tumors . Regarding the use of
[108]