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37 Artery-First Approach inPancreaticoduodenectomy
295
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36. Ironside N, Barreto SG, Loveday B, Shrikhande SV, Windsor JA,
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37. Jiang X, Yu Z, Ma Z, etal. Superior mesenteric artery rst approach
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Organ- and Parenchyma-sparing Pancreatic Surgery
CalogeroIacono, MarioDe Bellis, AndreaRuzzenente,
andAlfredoGuglielmi
38
Abstract
Conventional pancreatectomies, such as pancreaticoduodenectomy and distal and total pancreatectomy, result in
an important loss of normal pancreatic parenchyma and
the nearby organs (spleen, upper digestive tract, and
common bile duct). In addition, these procedures involve
signicant mortality, high morbidity, and long-term disorders, including infections, thromboembolic complications, digestive disorders, pancreatic exocrine
insufciency, and diabetes. Although conventional pancreatectomies are mandatory for malignant tumor, they
are an overtreatment for benign tumors as healthy functional pancreatic parenchyma is sacriced, especially in
young patients with long life expectancy. Unfortunately,
enucleation is not always advisable in lesions of uncertain
histology or those deeply located in the pancreatic gland
owing to the risk of a positive surgical margin or injury to
the main pancreatic duct, respectively. Since the 1980s,
the prospects for pancreatic resection have widened with
the development of organ- and parenchyma-sparing pancreatic surgery (OPSPS) for benign or low-grade malignant tumors involving isolated or multiple segments of
the pancreas. New operations, such as spleen-preserving
distal pancreatectomy, duodenum-sparing pancreas head
resection, dorsal pancreatectomy, resection of the ventral
or uncinate process of the pancreas, middle-preserving
pancreatectomy, and central pancreatectomy (the
Dagradi-Serio-Iacono operation), aim to preserve pancreatic exocrine and endocrine function, spare the nearby
organs, ensure oncological radicality, and achieve better
quality of life after surgery. In fact, according to vascular
anatomy and embryological development, the pancreatic
gland is divided in four segments and each of these can be
resected independently. In experienced hands, OPSPS is
C. Iacono (*) · M. De Bellis · A. Ruzzenente · A. Guglielmi
Department of Surgery, Unit of HPB Surgery, University of Verona
Medical School, Verona, Italy
e-mail: calogero.iacono@univr.it
technically feasible and can be performed with low mortality. Early morbidity is greater than that achieved using
standard resection owing to the high rate of postoperative
pancreatic stula. However, most of these pancreatic
leakages are managed conservatively. Furthermore, possible poor short-term outcomes are counterbalanced by
the preservation of pancreatic endocrine and exocrine
function and the low rate of reoperations for tumor recurrence. Currently, OPSPS can also be performed by laparoscopic or robotic approach achieving better results in
term of blood loss, operative time, hospital stay, recovery
and scarring. Careful case selection, accurate pre- and
intraoperative evaluation of the lesion, and experience in
pancreatic surgery are required for optimal results.
38.1 Introduction
Conventional pancreatic resections for malignant and benign
tumors are pancreaticoduodenectomy (PD), distal pancreatectomy (DP), and total pancreatectomy (TP). Severe morbidity remains high despite advances in decreasing
postoperative mortality below 4%, as reported by highvolume centers. In addition, these standard surgical procedures are associated with long-term disorders, including
infections, thrombotic complications, digestive disorders,
pancreatic exocrine insufciency, and diabetes.
Conventional pancreatectomies are mandatory for malignant tumors; however, they are considered an overtreatment
of benign tumors as the healthy functional pancreatic parenchyma is sacriced, especially in young patients with long
life expectancy. In fact, standard pancreatic resections are
burdened by disappointing results in terms of decit in endocrine and exocrine function in the long term. This has a negative impact on quality of life (QOL) and increases the cost of
pancreatic enzyme replacement therapy and anti-diabetic
drugs. Furthermore, because overall survival after pancreatic
resections continues to improve, postoperative pancreatic
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_38
297
298
C. Iacono et al.
insufciency has become increasingly important to consider
as may lead eventually to malnutrition, maldigestion, and
nutritional deciencies. The frequency, degree, and longterm persistence of endocrine and exocrine dysfunction varies depending on pre-existing conditions, benign or malignant
diseases, the amount of pancreatic parenchyma saved, the
pancreatic resection type, and follow-up duration. Roughly,
the incidence of new-onset diabetes mellitus (NODM) and
exocrine pancreatic insufciency after PD is 22% and 53%,
respectively [1]. Likewise, the incidence of NODM in
patients undergoing DP ranges 14–39% [2]. Many patients
subsequently develop insulin-dependent diabetes mellitus.
In theory, pancreatic enucleation (EN) is the most optimal
surgical option used to preserve the maximum amount of
normal parenchyma and reduce the risk of endocrine and
exocrine insufciency. Surgeons also favor this method
because it does not require digestive tract reconstruction.
Nevertheless, the benets of this approach could be jeopardized by an increase in tumor recurrence and postoperative
morbidity. In fact, EN is contraindicated in malignant cases,
and it is not advisable in tumors of uncertain histology since
it does not ensure an adequate surgical margin nor facilitate
systematic regional lymph node dissection. Moreover, EN
can only be performed when the lesion fullls anatomic and
technical considerations. The relationship between the lesion
and the main pancreatic duct (MPD) is the most important
and limiting factor. Indeed, duct injury can lead to highoutput and prolonged pancreatic stula (PF), a source of
severe postoperative complications. Thus, EN can be performed in a minority of patients diagnosed with pancreatic
lesions; the selection is based on the biological behavior and
localization of the tumor within the pancreatic parenchyma.
Since the 1980s, the prospects for pancreatic resection have
widened owing to the development of organ- and parenchymasparing pancreatic surgery for tumors involving isolated or
multiple segments of the pancreas. In fact, according to vascular anatomy and embryological development, the pancreatic
gland can be divided into four segments (i.e., the anterior head,
body, and tail [originating from dorsal pancreas] and the posterior head [ventral pancreas]), and each one can be resected
independently [3]. These new operations, such as spleen-preserving DP (SPDP), duodenum- preserving pancreatic head
resection (DPPHR), central pancreatectomy (CP), dorsal pancreatectomy, the resection of the ventral or uncinate process of
the pancreas, and middle-preserving pancreatectomy (MPP),
aim to preserve pancreatic exocrine and endocrine function,
spare the nearby organs, ensure oncological radicality, and
achieve better QOL after surgery.
The main indications for OPSPS are: (1) benign or lowgrade malignant tumors (neuroendocrine tumors, serous and
mucinous cystadenomas, noninvasive branch duct type intraductal papillary mucinous neoplasms (IPMN) [4], and small
solid pseudopapillary tumors, (2) non-neoplastic cysts (sim-
ple lymphoepithelial or hydatid cysts) not suitable for EN,
and (3) isolated pancreatic metastases (especially from renal
cancer).
38.2 Organ-Sparing Techniques
38.2.1 Spleen-Preserving Distal Pancreatectomy
SPDP should always be considered when patients have nonmalignant disease. Several middle- and long-term complications, such as abdominal abscesses, thrombocytosis,
pulmonary hypertension, venous and arterial thrombosis,
and overwhelming infection, have been described after splenectomy. Furthermore, splenectomized patients should be
vaccinated against pneumococcus, Haemophilus inuenzae
type b, and meningococcus at additional cost to the national
health system. On the contrary, SPDP is associated with a
low rate of postoperative complications, especially infectious ones.
SPDP can be carried out in two different ways, either by
splenic vessels resection, as proposed by Warshaw, or by
splenic vessels preservation, as proposed by Kimura
(Fig.38.1). The resection of splenic vessels reduces blood
supply to the spleen, along with the risk of splenic infarction,
which requires a subsequent splenectomy. Moreover, an
increased blood ow through the short gastric veins may
cause gastric varices, with a consequent small risk of bleeding. Both procedures can be performed using a minimally
invasive [5] or open approach; however, splenic vessels preservation ensures better outcomes. Some surgeons have
expressed concerns about Warshaw’s procedure and would
rather perform a splenectomy if splenic vessels preservation
is unfeasible.
38.2.2 Duodenum-Preserving Pancreatic Head
Resection
Growing evidence supports the use of DPPHR to remove
benign lesions located in the pancreatic head. Nonetheless, the
use of the DPPHR involves two major challenges: oncological
radicality and having to avoid ischemic duodenal lesions.
Radical extirpation necessitates segmental resection of
the duodenal wall in the peripapillary region. Although dissection of the pancreatic head from the duodenal wall (i.e.,
roughly 3cm on both sides of the papilla major) is easy to
perform, total resection of the pancreatic head can result in
devascularization of the duodenal segment, with the risk of
ischemic lesions.
Blood supply to the duodenum is provided by the anterior and posterior branches of the gastroduodenal artery
38 Organ- and Parenchyma-sparing Pancreatic Surgery
ab
c d
299
Fig. 38.1 Spleen preserving distal pancreatectomy with splenic ves-
sels preservation for a mucinous cystadenoma of the pancreatic body/
tail. Intraoperative image showing a large pancreatic cystic lesion of the
(GDA) and the corresponding branches of the inferior pancreaticoduodenal arcades and the supraduodenal artery.
The papilla of Vater maintains the blood supply derived
from the posterior GDA and the posterior branches of the
inferior pancreaticoduodenal artery. Dissection of the pancreatic head results in an interruption to the arterial blood
and nerve supply to the papilla area and surrounding duodenal wall.
To avoid ischemic lesions in the duodenal segment, preservation of the anterior inferior pancreaticoduodenal arcade,
which runs along the duodenal wall, and the anterior superior
pancreaticoduodenal arcade from the GDA, is necessary.
Conversely, the posterior superior and inferior pancreatoduodenal arcades may be completely divided without negatively
impacting regarding duodenal wall perfusion.
DPPHR and conventional PD outcomes compare favorably. Notably, the DPPHR procedure preserves pancreatic
body/tail (a). Isolation of the pancreatic body/tail from splenic vein (b).
Preservation of splenic artery and vein (c). Pancreatic specimen (d)
endocrine and exocrine function and is characterized by low
rates of surgery-related morbidity, clinically relevant PF,
reinterventions, and hospital mortality [6].
38.3 Parenchyma-Sparing Techniques
38.3.1 Central Pancreatectomy (The DagradiSerio- Iacono Operation)
CP is a segmental pancreatic resection that is indicated for
the removal of benign or low-grade malignant isthmus
tumors and proximal part of the pancreas body (Fig.38.2). It
is also known as middle pancreatectomy, medial pancreatectomy, intermediate pancreatectomy, limited conservative
pancreatectomy, and the Dagradi-Serio-Iacono operation [7].
This technique was rst performed for an insulinoma of the
300
C. Iacono et al.
a
c
b
d
e
Fig. 38.2 Central pancreatectomy for an insulinoma of the pancreatic
isthmus. Small hypervascular lesion in the neck of the pancreas (black
arrow) showed by angiography (a). Intraoperative image of the pancreas with no visible lesion (b). Intraoperative ultrasonography shows
the tumor (*) deeply located in the pancreatic parenchyma, superior
mesenteric vein (SMV), superior mesenteric artery (SMA), and splenic
vein (SV) (c). Proximal and distal pancreatic stumps after resection of
f
the pancreatic isthmus (d). Pancreatic specimen cut open to show the
relationship between the insulinoma and the Wirsung’s duct (e). The
proximal pancreatic stump can be closed with “mattress” stitches after
selective closure of the main pancreatic duct with a gure-of-eight
stitch and the distal pancreatic stump can be anastomosed with the jejunum by a Roux-en-Y end to end pancreaticojejunostomy (f)
a
38 Organ- and Parenchyma-sparing Pancreatic Surgery
301
pancreatic isthmus in 1982. A few years later, it was described
in the Enciclopedia Medica Italiana by Dagradi and Serio.
Subsequently, Iacono validated it using functional endocrine
and exocrine tests, popularizing it worldwide [8].
Incisions are made in the posterior peritoneum along the
superior and inferior margins of the central segment of the
pancreas. After passing a vessel loop around the isthmus,
the spleno-mesenteric axis is dissected free from the posterior surface of the gland dividing some pancreatic veins.
Another vessel loop is passed around the splenic artery, and
its collaterals, including the dorsal pancreatic artery, are
divided.
Fig. 38.3 Anatomical
vascular contraindication to
central pancreatectomy.
Schematic representation of
the Mellière and Moullè type
III vascularity of the pancreas
(a). Angiography shows
pancreatic vascularization of
the body/tail maintained
exclusively by the transverse
pancreatic artery (white
arrow), that is the left branch
of the dorsal pancreatic artery
(red arrow) (b). Spleenpreserving distal
pancreatectomy with splenic
vessel preservation can be
performed instead of central
pancreatectomy (c)
b
Surgeons should be aware that a large dorsal pancreatic
artery raises a high index of suspicion of a pancreatic vascularization of the body/tail maintained exclusively by the
transverse pancreatic artery (i.e., the left branch of the dorsal pancreatic artery). This vascular variant (type III,
according to Mellière and Moullè) means that CP is contraindicated owing to the risk of necrosis in the left pancreas
(Fig.38.3).
The transection limit of the gland is the GDA on the
cephalic side, while on the caudal side the authors suggest
sparing at least 5cm of pancreatic tail with no signs of atrophy. The specimen should be sent to the pathologist for the
c
302
C. Iacono et al.
frozen section procedure to conrm the diagnosis and determine if the resection margin is tumor-free. In the case of a
positive surgical margin, the resection can be extended further, but if the pathologist diagnoses malignant disease, the
operation has to switch to PD or DP with extended lymphadenectomy, depending on extension of the lesion toward the
pancreatic head or body/tail.
If IPMN are identied, pancreatoscopy can be performed,
just after resection, through MPD in both stumps to rule out
other ductal lesions. The cephalic stump can be closed with
“mattress” stitches after separate closure of the MPD with a
gure-of-eight stitch. The distal pancreatic stump should be
separated from the splenic vessels by two centimeters to easily carry out the anastomosis of the digestive tract.
associated with higher rates of postoperative PF.In fact, CP
has two points of “weakness”, the proximal head stump and
the distal one, which is anastomosed to the digestive tract.
Furthermore, since CP is indicated for benign or low-grade
malignant tumors, the anastomosis is usually performed on a
soft pancreas with a nondilated MPD and this entails a high
risk of stula. However, PF following CP is classied as a
biochemical leak or postoperative PF grade B according to
the international study group of PF and it usually heals spontaneously with drainage management, parenteral nutrition,
and the administration of somatostatin analog drugs. In fact,
the leak from the proximal stump or from the pancreaticojejunostomy is not subject to the enzymatic activation of bile,
as is the case of a PF after PD [10].
Reconstruction can be performed using either Roux-en-Y
pancreaticojejunostomy or pancreaticogastrostomy.
Pancreaticojejunostomy can be conducted in different ways,
38.3.2 Dorsal Pancreatectomy
for example, end to end (simple or telescopic invagination),
end to side, duct to mucosa, and side to side (Puestow procedure or Partington-Rochelle technique if the duct of Wirsung
is dilated, for example, in the case of chronic pancreatitis).
Dorsal pancreatectomy is a conservative surgical technique
that allows for complete removal of the dorsal portion of the
pancreatic head, along with the pancreatic neck, body, and tail.
Some authors also perform an anastomosis of the cephalic
stump using the same jejunal loop (double pancreaticojejunostomy). Pancreaticogastrostomy is usually performed by
the implantation of the open end of the pancreas directly into
the gastric pouch through a 2–3cm opening in the posterior
surface.
The disadvantages of this type of reconstruction primarily
relate to alterations to the digestive enzymes, particularly
lipase, caused by gastric acid, which results in exocrine function impairment. In our opinion, alterations to exocrine pancreatic function signify the failure of this conservative
surgical technique. Closure of the distal pancreatic stump
can be performed in exceptional cases as atrophy of the remnant pancreas or MPD not evident. Instead, closure of the
MPD of the distal stump, using injected synthetic glue,
causes pancreatic atrophy and diabetes; therefore, we do not
recommend this technique. End-to-end anastomosis of the
MPD and parenchyma, with or without stent placement for
internal or external pancreatic juice drainage, is another type
of reconstruction [9]. The key benet of this kind of reconstruction is complete mobilization of the distal pancreatic
remnant achieved through peripancreatic ligament transection, which, in turn, pulls the two pancreatic stumps together.
In the past, this technique was used to repair traumatic pancreatic neck transections with minimal loss of parenchyma.
Notably, the MPD of most patients who undergo CP is too
thin (not dilatated) to condently perform duct-to-duct
anastomosis.
The aim of CP is to preserve the functional tissue of the
dorsal and ventral primordia. During the sixth week of
embryonic development, the ventral primordium, along with
the developing bile duct, rotates clockwise behind the duodenum and the dorsal primordium. The differences in embryologic origin reect the histological characteristics. In fact,
compared with the dorsal pancreas, the ventral pancreas is
characterized by smaller and densely packed lobuli, irregular
islets of Langerhans, and rich immunostaining with antipancreatic polypeptide. The dorsal pancreas comprises the
pancreatic neck, body, and tail, as well as the anterior segment of the head. The ventral pancreas makes up the majority of the uncinate process and the posterior segment of the
head. Autoptic pancreatic anatomical studies have demonstrated that the pancreas head can be removed while preserving the vascular arcades and branches to the duodenum, the
common bile duct (CBD), and the papilla of Vater and that
there is an anatomical fusion plane between the dorsal and
ventral pancreas that contains small pancreatic ducts and
vascular collateral branches. The embryological fusion plane
contains a few communicating vessels or ducts (except for
the junction of the dorsal and ventral duct systems, present in
over 90% of cases). The presence of pancreas divisum,
namely the lack of fusion between the dorsal and ventral
pancreas during embryological development, is a favorable
anatomical condition that promotes easier pancreatic segmental resection. Nevertheless, the procedure is still technically feasible and safe when the normal pancreatic fusion
plane is present.
pancreatic body/tail segment where there are numerous islet
cells; however, compared with DP and PD, this technique is
and digestive tract resection and reconstruction, while pre-
The pancreas comprises two embryological segments, the
Dorsal pancreatectomy avoids the need to perform biliary
38 Organ- and Parenchyma-sparing Pancreatic Surgery
303
serving pancreatic endocrine and exocrine function. In
selected cases, this operation represents the only alternative
to TP and difculties managing the ensuing “fragile” diabetes. Although postoperative diabetes is commonly observed
after dorsal pancreatectomy, it is easier to control than that
resulting from TP because the glucose-stabilizing effect of
glucagon can be maintained.
To identify the intrapancreatic tract of the CBD in the
ventral segment, a catheter can be inserted through the
cystic duct to the duodenum. Alternatively, preoperative
endoscopic biliary and/or pancreatic stent placement can
be performed to facilitate the intraoperative identication
of CBD and MPD.Pancreatic resection is conducted from
the left (tail) to the right (head). At the head of the pancreas, the dorsal segment is dissected stepwise from the
duodenal wall toward the CBD plane, while preserving
the GDA and the anterior superior pancreaticoduodenal
artery. Sparing the anterior and posterior pancreaticoduodenal arcades enables mobilization of the duodenum
without ischemic risk. Santorini’s duct is identied, dissected, and ligated at its outlet into the duodenum, followed by dissection of the pancreatic parenchyma along
the anterior surface of the CBD.To complete the dorsal
pancreatectomy, the fusion plane between the dorsal and
ventral segments is identied and carefully dissected. The
MPD in the ventral segment of the dissected parenchymal
surface is identied and ligated using an unabsorbable
monolament suture. Frozen sections of the pancreatic
parenchymal margin should be collected and analyzed in
all cases. Branch ducts identied on the surface of the
ventral segment can be sutured in an interrupted pattern.
A methylene blue injection or intraoperative cholangiography through the trans-cystic catheter can be performed
to exclude damage to the CBD.If necessary, a T-tube can
be placed [11].
Head dorsal pancreatectomy, a segmental pancreatic
resection, performed to spare the pancreatic neck, body, and
tail, is a conservative form of total dorsal pancreatectomy.
Unlike total dorsal pancreatectomy, head dorsal pancreatectomy includes a reconstructive phase. The authors usually
perform an end-to-side, duct-to-mucosa pancreatojejunostomy with a Roux-en-Y method with transmesocolic transposition. The pancreatic duct is sutured to the jejunal mucosa
with interrupted stitches using 5-0 absorbable monolament
sutures and a plastic stent in the MPD.The pancreatojejunostomy is completed with interrupted stitches placed
between the seromuscular layer of the jejunum and the capsule of the pancreas using 4-0 absorbable monolament
sutures in both the posterior and anterior layers. End-to-side,
two-layer jejunum–jejunum anastomosis, approximately
50cm from the pancreatico-jejunum anastomosis, completes
the reconstruction [12].
38.3.3 Resection oftheVentral or Uncinate
Process ofthePancreas
Isolated resection of the ventral pancreas is reserved for
benign or low-grade malignant tumors exclusively impacting
the uncinate process. The preservation of maximal pancreatic parenchyma and the ow of normal pancreatic juice
through the duct of Wirsung are the main benets. In addition, the duodenum and the CBD are preserved, thereby
avoiding digestive anastomoses and reducing the morbidity
typically associated with extensive pancreatic resection.
Despite the clear advantages of this procedure, compared
to PD, isolated resection of the uncinate process of the pancreatic is rarely reported in the literature as it is a complex
operation that requires accurate knowledge of pancreatic
anatomy [13]. The uncinate process of the pancreas is merged
to the head, and its limits are not easy to identify, especially
its upper margin, which maintains a close relationship with
MPD which must be preserved. Usually, when using an open
or laparoscopic approach, the use of intraoperative ultrasound can assist with the identication of the MPD.However,
the MPD is frequently small and difcult to visualize.
Therefore, intraoperative cholangiography is recommended
in these situations.
In the absence of a gallbladder, the preoperative endoscopic placement of biliary and pancreatic plastic stents
should be considered to facilitate the intraoperative identication of the CBD and MPD.The uncinate process is dissected away from the superior mesenteric vein on its left
border; attention should be paid to the venous branches as
they can cause massive bleeding if the dissection plain is
inaccurate. In addition, in the lower and right limits of the
uncinate process an arterial arcade, formed by the inferior
pancreatic artery, is responsible for duodenal perfusion and
must be preserved. The dissection plane should preserve the
inferior pancreatic artery, while controlling its arterial
branches attached to the uncinate process. While performing
parenchymal transection, steps are taken to preserve the
MPD.
38.3.4 Middle-Preserving Pancreatectomy
Many diseases manifest as multiple lesions in the pancreas,
including IPMN, multiple endocrine neoplasia type I, von
Hippel-Lindau syndrome, and metastatic pancreatic cancer.
TP is currently regarded as the standard surgical treatment
for multiple lesions involving the entire pancreas. However,
pancreatic insufciency after TP leads to complex glucose
metabolism disorders and altered nutritional balance, signicantly compromising postoperative QOL.The postoperative
incidence of diabetes directly relates to the extent of pancre-
304
C. Iacono et al.
atic resection. Clinically, signicant malabsorption does not
occur until 85–90% of pancreatic enzyme output is lost. In
terms of endocrine function, there is usually little change to
glycemic control unless more than 80% of the pancreas is
resected in patients with a previously normal pancreas. The
pancreatic middle segment volume corresponds to approximately 25% of the entire gland, measured using computed
tomography (CT)-based pancreatic volumetry. Theoretically,
this implies that the use of MPP could preserve enough
parenchyma to reduce the risk of the patient developing
endocrine and exocrine insufciency [14]. MPP also preserves the glucagon-secreting alpha cells in the pancreatic
body, the loss of which is responsible for postoperative
hypoglycemic episodes, a major challenge after TP.
The objective of performing MPP is to combine right
resection of the head lesions with left resection of the body/
tail lesions, while preserving the pancreatic body segment
and its blood supply from the pancreatic dorsal artery. MPP
can be performed either by simultaneous PD and SPLP or as
a two-stage approach. First, the distal pancreatic parenchyma must be resected; if this margin is negative at the
frozen section, selective suture ligation of the MPD must be
performed on the transection plane on the raw surface of the
distal remnant. Thereafter, a PD is performed, and the proximal margin of the body is checked by a second frozen section. MPP results in a pancreatojejunostomy and a blunt
transection margin, which, has the potential to double the
risk of PF developing. A high PF incidence may also be
caused by ischemia of the pancreatic remnant. However, the
limited use of MPP does not permit denitive conclusions to
be drawn.
Other types of multiple pancreatic resections in the eld
of parenchyma-sparing surgery have been reported anecdotally (e.g., resection of the uncinate process combined with
CP as well as head dorsal pancreatectomy combined with
DP).
38.4 Conclusion
Recent advances in high-resolution multi-slice CT and magnetic resonance imaging for diagnosis and screening have
resulted in the incidental discovery of many benign, lowgrade, small-sized tumors of the pancreas in young and
middle- aged patients with long life expectancy. In these
patients, OPSPS could ensure a better QOL compared to
conventional pancreatectomies. In experienced hands, both
surgical strategies have a similar rate of low mortality.
Instead, early morbidity is higher with OPSPS due to the
high rate of PF.Nonetheless, most of these pancreatic leakage can be managed conservatively, and possible poor short-
term outcomes are counterbalanced by the preservation of
pancreatic endocrine and exocrine function.
Presently, OPSPS can be performed either by traditional
open resection or using a minimally invasive approach [15].
Laparoscopic and robotic surgery achieves similar outcomes
yielding lower blood loss, reduced operative time, shorter
hospital stay, faster recovery, and reduced scarring. Although
minimally invasive OPSPS requires a long learning curve,
we believe its implementation will enables to perform
increasingly complex resections, thereby ensuring enhanced
outcomes.
OPSPS is technically demanding and requires specic
surgical experience, so it is performed less frequently compared with conventional pancreatectomies, and it is mainly
conducted mainly in specialized centers. Hopefully,
increased condence in the treatment of PF and improvements in pancreatic neoplasm natural history knowledge will
encourage surgeons to preserve as much pancreatic parenchyma as possible. Careful case selection, accurate pre- and
intraoperative evaluations of the lesions, and thorough
knowledge of pancreas anatomy are recommended to obtain
optimal results.
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