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Basso et al. Mini-invasive distal pancreatectomy

Consistent with previous studies, [14,15] our operative Concerning morbidity, a large population-based
time for LDP was longer than for ODP (median 195.5 analysis reported a 25% reduction of overall
vs. 112.5 min). Shin et al. [22] reported a median perioperative complications, particularly related to a
operative time of 195 min for LDP, whereas lower rate of postoperative infections (30.1% vs. 39%)
[12]
Braga et al. [28] reported a median duration of surgery and bleeding complications (13.1% vs. 20.6%).
[14]
of 239 min for LDP, significantly higher than that for Similarly, Venkat et al. reported a reduction in
ODP (213 min), but their series included a high rate overall morbidity after the minimally invasive approach
(30%) of adenocarcinomas. Another group reported a (33.9% vs. 44.2%), including a lowering of the
longer operative time for LDP (376 min vs. 274 min). percentage of surgical site infections (2.9% vs. 8.1%).
[29]
In our series, the higher operative time was related However, most of the reports found no differences in
[13]
to one operation (285 min) in an obese patient with complication rates between the two approaches.
[33]
diffuse adhesions, and three cases in which the size Magge et al. reported equal rates and severity
of the specimens necessitated a Pfannenstiel incision, of complications (39% vs. 50%) in 62 patients
also lengthening the duration of surgery. Interestingly, undergoing distal pancreatectomy for early-stage
we found that in both groups age did not affect ductal adenocarcinoma, and found that conversion to
operative time, which was related to intraoperative an open procedure was associated with poor outcome.
[34]
bleeding, whereas a significant relationship between Similarly, Jayaraman et al. compared 343 LDP
the operative time and BMI only occurred in the ODP vs. 236 ODP and found that patients who required
group. conversion had more complications and pancreatic
leaks. These findings confirm the need for accurate
Undoubtedly, standardization of the technique and preoperative patient selection, to identify patients
expertise of the surgical team is crucial. Another at high risk for conversion and to choose the best
systematic review found no difference in operative time approach for each patient and disease presentation.
on 488 patients treated laparoscopically and 573 cases Post-operative pancreatic fistulas (POPF) remain the
with open approach (mean 220.4 vs. 208.6 min). [27]
most feared complication, but the incidence is variable
In agreement with previous studies and meta- among different surgeons, partly because of different
analyses, we encountered lower intraoperative blood definitions of POPF. We strictly applied the International
loss in the minimally invasive group. A wide population- Study Group for Pancreatic Fistulae (ISGPF) definition
of POPF and, considering only grade B and C fistulae,
based analysis reported a lower rate of bleeding we found no differences between the two groups, with
complications in LDP (13.1% vs. 20.6%) and also one case of POPF in both (8.3%). A large multicenter
[9]
a reduction of transfusion rate (11.3% vs. 18%). study, using the same ISGPF criteria, found no
[12]
However, the reported blood loss varies widely difference in pancreatic leaks between the laparoscopic
between studies, and may be related to the surgical and the open approach. [35] Similarly, a meta-analysis
technique or to the accuracy of the quantification of 18 studies reported a similar incidence of grade
of the bleeding. Jusoh et al. reported a mean B-C fistulae after either the laparoscopic or the open
[27]
operative blood loss of 237.4 mL in LDP versus approach. Velanovich et al. reported a rate of
[36]
[14]
562.4 mL in ODP, whereas Limongelli et al. [30] found POPF of 13% in both groups, whereas Kooby et al.
[37]
a blood loss of 160 ± 185 mL vs. 365 ± 215 mL, reported 26% POPF in LDP and 32% in ODP. Another
respectively. Interestingly, Rutz et al. reported an series showed 14% POPF in LDP (n = 70) vs. 13%
[7]
estimated blood loss of 113 ± 155 mL in LDP vs. after open surgery (n = 45), similar to the report of
210 ± 274 mL in ODP, further differentiating blood Corcione et al. [38] (10.4% in LDP). In contrast,
loss between a totally laparoscopic approach (LDP, Fox et al. reported a higher incidence of POPF in
[39]
76 ± 71 mL) and laparoscopic hand-assisted distal LDP (28.57%) compared to ODP (13.16%), but LDP
pancreatectomy (LHDP, 197 ± 244 mL). Very recently, led to only grade A fistulae, while all the grade B-C
a meta-analysis of short-term outcomes between fistulae occurred in the ODP group. The occurrence of
LDP and robotic-assisted distal pancreatectomy POPF varies widely between surgeons, and this may
(RADP) found a lower blood loss and a higher rate of be attributable to the criteria adopted for definition
spleen-preserving procedures in RADP. Thus, the rather than to the surgical technique. A meta-analysis
[31]
technological improvements and the magnified view of the most popular techniques (sutures, stapled
during laparoscopy are crucial for control of bleeding. closure, combination of both, with or without fibrin
Nevertheless, lower rates of bleeding where found in a glue) did not identify one as being the most safe. A
[40]
surgical series that excluded malignancies, suggesting multicenter RCT performed in 21 European hospitals
a major role for the size and histology of the tumor. [32] found that hand-sewn sutures and closure with stapler
138 Mini-invasive Surgery ¦ Volume 1 ¦ September 30