Pancreatic surgery is frequently associated with substantial postoperative morbidity, particularly involving pancreatic endocrine and exocrine dysfunction. Conventional pancreatic resections, such as pancreatoduodenectomy and distal pancreatectomy, involve removal of substantial functional pancreatic parenchyma and can be followed by long-term metabolic consequences, including new-onset diabetes mellitus and pancreatic exocrine insufficiency^[1-3]. These functional impairments are of particular concern in patients with benign or low-grade malignant pancreatic lesions, who are expected to achieve long-term survival.

Function-preserving pancreatic surgery has therefore gained increasing attention as a parenchyma-sparing strategy aimed at preserving pancreatic function while achieving adequate disease control^[4,5]. Procedures such as enucleation, central pancreatectomy, spleen-preserving distal pancreatectomy, and duodenum-preserving pancreatic head resection are increasingly performed in carefully selected patients, particularly those with pancreatic neuroendocrine tumors, solid pseudopapillary neoplasms, and cystic pancreatic lesions.

Alongside these developments, minimally invasive surgical approaches have further expanded the technical feasibility of function-preserving pancreatic procedures. Laparoscopic and robotic techniques may offer advantages in operative visualization, dissection precision, and postoperative recovery^[6-8]. However, these procedures remain technically demanding, and the available evidence regarding perioperative safety and functional outcomes of minimally invasive function-preserving pancreatic surgery remains limited, being largely derived from small and heterogeneous series^[9-11].

This study aimed to evaluate perioperative outcomes, postoperative complications, functional outcomes, and pathological characteristics in a consecutive single-center cohort undergoing minimally invasive function-preserving pancreatic surgery. By reporting our institutional experience, we sought to provide additional evidence regarding the safety, feasibility, and functional preservation of parenchyma-sparing pancreatic procedures in the minimally invasive setting.

In this single-center experience, minimally invasive function-preserving pancreatic surgery demonstrated acceptable perioperative safety, a manageable postoperative complication profile, and favorable functional outcomes in carefully selected patients with benign or low-grade pancreatic lesions. The absence of perioperative mortality and a clinically relevant POPF rate of 12.8% support the feasibility of minimally invasive parenchyma-sparing pancreatic procedures in experienced centers. Similar findings have been reported in recent series, indicating that minimally invasive enucleation and other parenchyma-sparing resections can achieve morbidity rates comparable to open surgery, with potential advantages in postoperative recovery and length of hospital stay; however, high-quality evidence remains limited^[5,11,12].

POPF remains the principal concern following function-preserving pancreatic surgery, as preservation of pancreatic parenchyma and transection in close proximity to the main pancreatic duct inherently increase the risk of pancreatic leakage^[13]. In the present cohort, although biochemical leakage was common, the incidence of clinically relevant POPF was relatively low compared with rates reported in several recent series of minimally invasive central pancreatectomy. These studies suggest that minimally invasive approaches are associated with comparable or even lower rates of clinically relevant POPF than open surgery, while offering the additional benefit of reduced intraoperative blood loss^[14,15]. Importantly, no patient in our series required reoperation, and severe morbidity was uncommon, indicating that although POPF was frequent, it was generally manageable within a minimally invasive treatment framework.

Beyond patient selection, several pragmatic, procedure-specific strategies in our institutional practice may have contributed to reducing the incidence and severity of clinically relevant POPF. Preoperative cross-sectional imaging was systematically reviewed to delineate the anatomical relationship between the lesion and the main pancreatic duct, thereby guiding operative planning. In one patient with a lesion in close proximity to the pancreatic duct, a deliberately limited local resection was performed, accompanied by selective placement of a prophylactic intraductal pancreatic stent to facilitate ductal drainage and reduce intrapancreatic pressure. This was not used routinely in our series and remains to be further optimized with increasing experience. Intraoperatively, ultrasonography was selectively employed in real-world practice, particularly in cases requiring additional assessment of tumor localization and the tumor–main pancreatic duct relationship, to facilitate precise parenchyma-sparing dissection and reduce the risk of ductal injury. It may also serve as a valuable adjunct for defining the optimal site of pancreatic transection and guiding more accurate tumor localization in parenchyma-sparing procedures. Postoperatively, closed-suction drains were routinely positioned adjacent to the resection site and securely fixed to ensure effective drainage. This approach was intended not only to monitor pancreatic leakage but also to reduce the risk of secondary complications, including infection or hemorrhage necessitating interventional drainage or reoperation. Collectively, these individualized, anatomy-based measures may partly explain why, despite a high incidence of biochemical leakage, clinically relevant POPF remained largely manageable in our cohort.

Function-preserving pancreatic surgery comprises a heterogeneous group of procedures, each associated with distinct technical challenges and complication risk profiles. Enucleation and central pancreatectomy are typically associated with higher fistula rates, largely due to limited resection margins and close proximity to the main pancreatic duct, whereas spleen-preserving distal pancreatectomy and duodenum-preserving pancreatic head resection involve more extensive dissection but may allow better ductal control^[16,17]. Recent studies have demonstrated that minimally invasive duodenum-preserving pancreatic head resection can be performed safely with acceptable outcomes when undertaken in high-volume centers by experienced surgeons^[18]. In our series, overall complication rates across different procedures were acceptable, suggesting that tailored, anatomy-based selection of parenchyma-sparing techniques is essential for balancing oncologic adequacy with functional preservation. Careful preoperative evaluation remains crucial for appropriate case selection, particularly when malignancy cannot be confidently excluded.

The adoption of minimally invasive techniques has further expanded the feasibility of function-preserving pancreatic surgery. Enhanced visualization, improved instrument articulation, and refined dissection planes provided by laparoscopic and robotic platforms may facilitate precise parenchyma-sparing resections while minimizing surgical trauma^[19-22]. Although these procedures remain technically demanding and are associated with a steep learning curve, this evolution parallels broader trends in minimally invasive pancreatic surgery, whereby robotic and laparoscopic approaches have gradually gained acceptance and are increasingly endorsed by contemporary guidelines for selected pancreatic resections when performed by specialized teams^[23]. Our experience, in which all procedures were performed by a single experienced pancreatic surgeon, underscores the importance of technical expertise and procedural consistency in achieving favorable outcomes.

Preservation of pancreatic endocrine function represents a key theoretical advantage of function-preserving pancreatic surgery. In the present study, new-onset diabetes mellitus occurred in only 7.7% of patients during follow-up, a rate substantially lower than that reported after conventional pancreatic resections. This finding supports the concept that preservation of pancreatic parenchyma translates into meaningful metabolic benefits, particularly in patients without pre-existing glucose intolerance. A recent comparison of laparoscopic enucleation vs. formal resection for pancreatic neuroendocrine neoplasms also suggests a potential advantage of parenchyma-sparing techniques in preserving endocrine function, although long-term data remain limited^[12]. Although longer follow-up is required to confirm the durability of these findings, the present results further reinforce the functional rationale for parenchyma-sparing approaches.

Pancreatic exocrine insufficiency is more difficult to interpret, given the complex interplay among pancreatic volume, ductal integrity, and postoperative inflammation. In our cohort, pancreatic exocrine insufficiency was identified in 28.2% of patients based on clinical symptoms, and symptoms were effectively controlled with pancreatic enzyme supplementation when required. Although this incidence is not negligible, it compares favorably with rates reported after standard pancreatic resections and underscores the multifactorial nature of postoperative digestive dysfunction. Parenchyma-preserving approaches, particularly for cystic pancreatic lesions, have been shown to preserve exocrine function without increasing the risk of severe complications, further supporting the functional benefits of these strategies in carefully selected patients^[4,24,25]. Importantly, most patients maintained satisfactory nutritional status, as indicated by only modest changes in body weight during follow-up.

When placed in the context of existing literature, our findings are consistent with previously reported experiences summarized in Table 5. Most available studies on minimally invasive function-preserving pancreatic surgery are retrospective, single-center series characterized by limited sample sizes and heterogeneous indications. Reported rates of clinically relevant POPF vary widely, and only a minority of studies have systematically assessed postoperative functional outcomes. In this context, the present study adds incremental evidence by integrating perioperative outcomes with systematic assessment of both endocrine and exocrine pancreatic function, thereby addressing an important gap in the current literature.

Several limitations of this study should be acknowledged. First, this was a retrospective, single-center study, which inevitably introduces selection bias and limits the generalizability of the findings. Second, the overall sample size was modest, and the cohort included heterogeneous pathological diagnoses, procedure types, and minimally invasive approaches, which restricted the ability to perform robust subgroup analyses and may have affected the interpretability of procedure-specific outcomes. Third, all operations were performed by a single experienced pancreatic surgeon. Although this ensured technical consistency and reduced inter-operator variability, it may also limit the extrapolation of our results to lower-volume centers or surgeons at an earlier stage of the learning curve. Fourth, pancreatic exocrine insufficiency was assessed primarily on the basis of clinical symptoms and the requirement for enzyme supplementation rather than standardized biochemical testing, which may have underestimated subclinical dysfunction. In addition, the follow-up duration was relatively short, precluding definitive assessment of long-term endocrine and exocrine durability as well as oncologic adequacy, particularly in patients with unexpected pathological findings. Furthermore, outcomes of other pancreatic procedures performed during the same period were not included for comparison, and this should be considered when interpreting the relative benefits of minimally invasive function-preserving surgery. These limitations suggest that the present findings should be interpreted cautiously and regarded mainly as descriptive evidence from a real-world institutional experience.

In conclusion, minimally invasive function-preserving pancreatic surgery appears to be a feasible and safe option for carefully selected patients with benign or low-grade pancreatic lesions, offering acceptable perioperative outcomes and preservation of pancreatic function when performed within a standardized framework by experienced surgeons. Further multicenter studies with larger cohorts, longer follow-up, and more standardized functional assessments are warranted to refine patient selection and clarify the long-term value of these parenchyma-sparing approaches.