The study by Chiacco et al. published in the current issue of Revista Argentina de Cirugía is an observational and retrospective study on the experience of the Hepatobiliary and Pancreatic Surgery section of Hospital Militar Central in laparoscopic left pancreatectomy¹.

The laparoscopic approach to treat lesions located in the body and tail of the pancreas is becoming increasingly common. This approach was indicated in 76% of the cases in this study, revealing the experience of the treating team. The use of laparoscopy depends on surgeon’s case volume². In general, the main indication for laparotomy is the proximity of the tumor to the mesentericoportal axis or to the celiac trunk. Laparoscopic vascular resection should only be performed by surgeons with considerable experience in conventional pancreatic surgery and high-complexity laparoscopic procedures. In our group, the relationship between laparotomy and laparoscopy gradually became inverted as the experience in laparoscopic pancreatic surgery increased. Initially, in 2007, 90% of surgeries were performed through the conventional approach, leaving laparoscopy for specific cases, while in 2021, 96% of the patients (26 out of 27) were directly approached by laparoscopy.

All the procedures performed by hepatobiliary and pancreatic surgeons of Hospital Militar Central included splenectomy. I fully agree with performing splenectomy systematically in left pancreatectomy. Preservation of the spleen involves either preserving the splenic vessels (restricted to benign and small tumors) or using the Warshaw technique, which consists of preserving blood supply to the spleen exclusively through the short vessels, since the splenic vessels are sectioned³. The problem of this surgical technique is the development of varicose veins in the gastrosplenic circulation and loss of spleen function after the splenic artery is sectioned. In our experience with the Warshaw surgery, the development of perigastric varicose veins occurred in almost 70% of the patients; 2 of them presented gastrointestinal bleeding due to rupture of submucosal varices⁴. For this reason, we routinely perform splenectomy. Another technical aspect to highlight is ligating and sectioning the splenic artery first and then continuing with the splenic vein. Ligation of the splenic vein first is probably technically simpler in many cases, but the problem is that it generates venous congestion of the spleen, hindering its manipulation at the time of splenectomy. This venous congestion could generate intraoperative bleeding and condition the need for conversion to laparotomy.

Pancreatic fistula is one of the most common complications of this surgery, with an incidence between 30 and 40% in the international literature⁵. The laparoscopic approach does not differ from conventional pancreatectomy in terms of postoperative complications⁹. The development of pancreatic fistula will depend on the contexture of the pancreatic tissue and fatty infiltration of the pancreas, and not on the mechanism used to section the parenchyma. The use of mechanical stapler, transection using electric scalpel or even monopolar scalpel and staple line reinforcement do not change the incidence of pancreatic fistula⁶.

Another interesting topic for discussion is the indication of laparoscopy in malignant tumors. The minimally invasive approach is fully indicated for the treatment of pancreatic ductal adenocarcinoma, if the same procedure performed by conventional surgery can be reproduced by laparoscopy. Dissection in ductal adenocarcinoma is probably more difficult than resection for benign or premalignant lesions, since it involves splenectomy, resection of Gerota’s fascia, full lymphadenectomy or even radical antegrade modular pancreatosplenectomy (RAMPS)⁷. Van Hilst performed a randomized study comparing laparoscopic and conventional left pancreatectomy for ductal adenocarcinoma⁸. Although more lymph nodes were resected by conventional surgery, the results of the study did not show any differences in terms of survival. Therefore, the study demonstrates that laparoscopic surgery is totally feasible to perform in pancreatic cancer.

The laparoscopic approach has all the advantages of a minimally invasive approach, as less intraoperative bleeding, shorter length of hospital stay, earlier initiation of oral feeding, and better esthetic outcomes. As it was previously mentioned, there are no differences in the type and number of complications. This was demonstrated in the LEOPARD randomized study carried out by a Dutch group, which compared the laparoscopic and the conventional approaches⁸. From the technical point of view, there should be no differences either, since laparoscopy should reproduce what is performed by open surgery. The learning curve is an important aspect to highlight. It should show a gradual increase. In the initial stage, patients with benign or premalignant tumors distant from the mesentericoportal axis should be selected. As experience is gained, resections can be performed on malignant disease and larger tumors. Conversion to laparotomy is not a complication; on the contrary, conversion can often help the patient because, if resection is not possible due to technical difficulties, laparotomy can be used to solve this type of situation. That is why the operating surgeon must have extensive experience in conventional pancreatic surgery. The benefits of a shorter surgery via laparotomy are greater than those of a longer laparoscopic surgery.

In conclusion, the laparoscopic approach is a completely safe approach when performed in high-volume centers and by surgeons specialized in both pancreatic surgery and high-complexity laparoscopic surgery. The most common contraindications for this approach are the proximity to the celiac trunk and to the mesentericoportal axis. Other contraindication is the need for multivisceral resection. In the near future, the laparoscopic approach will probably be the gold standard treatment for tumors of the body and tail of the pancreas.