Journal of Gastrointestinal Surgery

, Volume 11, Issue 12, pp 1607–1622 | Cite as

Curative Laparoscopic Resection for Pancreatic Neoplasms: A Critical Analysis from a Single Institution

  • Laureano Fernández-CruzEmail author
  • Rebeca Cosa
  • Laia Blanco
  • Sammy Levi
  • Miguel-Angel López-Boado
  • Salvador Navarro


Laparoscopic pancreatic surgery (LPS) has seen significant development but much of the knowledge refers to small and benign pancreatic tumors. This study aims to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with benign, premalignant, and overt malignant lesions of the pancreas. This study, currently, is the largest single center experience worldwide. One hundred twenty-three consecutive patients underwent laparoscopic pancreatic surgery from April 1998 to April 2007, 20 patients with cysts or pseudocysts for acute and chronic pancreatitis, laparoscopic pancreatic drainage was performed, and were excluded from the analysis. The 103 patients were divided based on preoperative diagnosis: group I, inflammatory tumors for chronic pancreatitis (eight patients); group II, cystic pancreatic neoplasms (29 patients); group III, intraductal papillary mucinous neoplasms (10 patients); group IV, neuroendocrine pancreatic tumors (NETs) (43 patients); and group V ductal adenocarcinoma (13 patients). The median tumor size was 5.3 cm. Pathologic data include R 0 or R 1 resection (transection margins on the specimen were inked). Perioperative data, postoperative complications, and resection modalities were compared using statistical analysis. Long-term outcomes were analysed by tumor recurrence and patient survival. The overall conversion rate was 7%. Laparoscopic distal pancreatic resection was performed in 82 patients (79.6%). Laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP) was performed in 52 patients (63.7%), but with splenic vessels preservation in 22% and without splenic vessels preservation in 41.5%. Laparoscopic en-bloc splenopancreatectomy (Lap SxDP) was performed in 30 patients (36.6%) and laparoscopic enucleation (Lap En) in 20 patients (19.4%). There was no mortality. The overall complication rate was 25.2, 16.7, and 40% after Lap SPDP, Lap SxDP, and Lap En, respectively. The overall morbidity rate was significantly higher (p > 0.05) in the group of Lap SPDP without splenic vessels preservation comparing with Lap SPDP with splenic vessels preservation because of the occurrence of splenic complications (20.6%). The overall pancreatic fistulas was 7.7, 10, and 35% after Lap SPDP, Lap SxDP, and Lap En, respectively; the severity of fistula was significantly higher in the Lap En group (p > 0.05). The mean hospital stay was within 1 week in all groups, except in the group of ductal adenocarcinoma, which is 8 days. In this series, 27 patients (26.2%) had malignant disease. R 0 resection was achieved in 90% of ductal adenocarcinoma and 100% for other malignant tumors. The median survival for ductal adenocarcinoma patients was 14 months. This series demonstrates that LPS is feasible and safe in benign-appearing and malignant lesions of the pancreas.


Laparoscopic pancreatic surgery Laparoscopic pancreatic malignancies Laparoscopic neuroendocrine tumors Laparoscopic cystic neoplasms Laparoscopic pancreatic techniques Laparoscopic pancreatic complications 



We thank Tom Gorey Professor of Surgery in Dublin (Ireland) for the article preparation.


  1. 1.
    Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 1994;8:408–410.PubMedCrossRefGoogle Scholar
  2. 2.
    Cushieri A. Laparoscopic surgery of the pancreas. JR Coll Surg Edinb 1994;39:187–194.Google Scholar
  3. 3.
    Cuschieri A, Jakimowicz J. Laparoscopic pancreatic resections. Semin Laparosc Surg 1998;5:168–179.PubMedGoogle Scholar
  4. 4.
    Fabre JM, Dulucq JL, Vacher C, Lemoine MC, Wintringer P, Nocca D. Is laparoscopic left pancreatic resection justified? Surg Endosc 2002;19:507–510.Google Scholar
  5. 5.
    Patterson EJ, Gagner M, Salky B, Inabnet WB, Brower S, Edye M, Gurland B, Reiner M, Pertsemlides D. Laparoscopic pancreatic resection: Single-institution experience with 19 patients. J Am Coll Surg 2001;193:281–287.PubMedCrossRefGoogle Scholar
  6. 6.
    Shimizu S, Tanaka M, Mizumoto K, Yamaguchi K. Laparoscopic pancreatic surgery: Current indications and surgical results. Surg Endosc 2004;18:402–406.PubMedCrossRefGoogle Scholar
  7. 7.
    Fernández-Cruz L, Sáenz A, Astudillo E, Martinez I, Hoyos S, Pantoja JP, Navarro S. Outcome of laparoscopic pancreatic surgery: Endocrine and nonendocrine tumors. World J Surg 2002;26:1057–1065.PubMedCrossRefGoogle Scholar
  8. 8.
    Edwin B, Mala T, Mathisen O, Gladhayg I, Buanes T, Lunde OC, Soreide O, Bergan A, Fosse E. Laparoscopic resection of the pancreas: A feasibility study of the short-term outcome. Surg Endosc 2004;18:407–411.PubMedCrossRefGoogle Scholar
  9. 9.
    Velanovich V. Case-control comparison of laparoscopic versus open distal pancreatectomy. J Gastrointest Surg 2006;10:95–98.PubMedCrossRefGoogle Scholar
  10. 10.
    Park AE, Heniford BT. Therapeutic laparoscopy of the pancreas. Ann Surg 2002;236:149–158.PubMedCrossRefGoogle Scholar
  11. 11.
    Berends FJ, Cuesta MA, Kazemier G, van Eijck CH, de Herder WW, van Muiswinkel JM, Bruining HA, Bonjer HJ. Laparoscopic detection and resection of insulinomas. Surgery 2000;128:386–390.PubMedCrossRefGoogle Scholar
  12. 12.
    Gramatica L, Herrera MF, Mercado-Luna A, Sierra M, Verasay G, Brunner N. Videolaparoscopic resection of insulinomas: Experience in two institutions. World J Surg 2002;26:1297–1300.PubMedCrossRefGoogle Scholar
  13. 13.
    Ihiara M, Obara T. Minimaly invasive endocrine surgery: Laparoscopic resection of insulinomas. Biomed Pharmacother 2002;56:227–230.CrossRefGoogle Scholar
  14. 14.
    Ayav A, Bresler L, Brunand L, Boissel P. Laparoscopic approach for insulinoma: A multicenter study. Langenbecks Arch Surg 2005;390:134–140.PubMedCrossRefGoogle Scholar
  15. 15.
    Fernández-Cruz L, Martinez I, Cesar-Borges G, Astudillo E, Orduña D, Halperin I, Semilo G, Puig M. Laparoscopic surgery in patients with sporadic and multiple insulinomas associated with multiple endocrine neoplasia type 1. J Gastrointest Surg 2005;9:381–388.PubMedCrossRefGoogle Scholar
  16. 16.
    Assalia A, Gagner M. Laparoscopic pancreatic surgery for islet cell tumors of the pancreas. World J Surg 2004;28:1239–1247.PubMedCrossRefGoogle Scholar
  17. 17.
    Sa Cunha A, Beau C, Rault A, Catargi B, Collet D, Masson B. Laparoscopic versus open approach for solitary insulinoma. Surg Endosc 2007;21:103–108.CrossRefGoogle Scholar
  18. 18.
    Mabrut JY, Fernández-Cruz L, Azagra JS, Bassi C, Delvaux G, Weerts J, Fabre JM, Boulez J, Baulieux Peix JL, Gigot JF. Laparoscopic pancreatic resection: Results of a multicenter European study of 127 patients. Surgery 2005;137:597–605.PubMedCrossRefGoogle Scholar
  19. 19.
    Fernández-Cruz L, Martinez I, Gilabert R, Cesar-Borges G, Astudillo E, Navarro S. Laparoscopic distal pancreatectomy combined with preservation of the spleen for cystic neoplasms of the pancreas. J Gastrointestl Surg 2004;8:493–501.CrossRefGoogle Scholar
  20. 20.
    Fernández-Cruz L. Distal pancreatic resection: Technical differences between open and laparoscopic approaches. HPB 2006;8:49–56.PubMedGoogle Scholar
  21. 21.
    Strasberg SM, Drebin JA, Linehan D. Radical antegrade modular pancreatosplenectomy. Surgery 2003;133:521–527.PubMedCrossRefGoogle Scholar
  22. 22.
    Fernández-Cruz L, César-Borges G. Laparoscopic strategies for resection of insulinoma. J Gastrointest Surg 2006;10:752–760.PubMedCrossRefGoogle Scholar
  23. 23.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138:8–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Talamini MA, Moesinger R, Yeo CJ, Poulose B, Hruban RH, Cameron JL, Pitt HA. Cystadenomas of the pancreas: Is enucleation an adequate operation? Ann Surg 1998;227:896–903.PubMedCrossRefGoogle Scholar
  25. 25.
    Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: Indications and outcomes in 235 patients. Ann Surg 1999;229–693.Google Scholar
  26. 26.
    Fernández del Castillo C, Rattner DW, Washaw I. Standards for pancreatic resection in the 1990s. Arch Surg 1995;130:295–300.PubMedGoogle Scholar
  27. 27.
    Benoist S, Dugue L, Sauvanet A, Valverde A, Mauvais F, Paye F, Farges O, Belghiti J. Is there a role of preservation of the spleen in distal pancreatectomy? J Am Coll Surg 1999;188:255–260.PubMedCrossRefGoogle Scholar
  28. 28.
    Shoup M, Brennan MF, Mc White K, Leung DH, Klimstra D, Conlon KC. The value of splenic preservation with distal pancreatectomy. Arch Surg 2002;137:164–168.PubMedCrossRefGoogle Scholar
  29. 29.
    Kimura W, Inone T, Futawake N, Shiukai H, Hau I, Muto T. Spleen preserving distal pancreatectomy with conservation of the splenic artery and vein. Surgery 1996;120:885–890.PubMedCrossRefGoogle Scholar
  30. 30.
    Warshaw L. Conservation of the spleen with distal pancreatectomy. Arch Surg 1998;123:550–553.Google Scholar
  31. 31.
    Warshaw A. Letter to the editor. Techniques of preserving the spleen with distal pancreatectomy. Surgery 1997;121:974.CrossRefGoogle Scholar
  32. 32.
    Shein M, Freinkel W, D’Egidio A. Splenic conservation in distal pancreatic injury: Stay away from the hilium! J Trauma 1991;31(3):letter.Google Scholar
  33. 33.
    Balzano G, Zerbi A, Cristallo M, Di Carlo V. The unsolved problem of fistula after pancreatectomy: The benefit of cautions drain management. J Gastrointest Surg 2005;9:837–842.PubMedCrossRefGoogle Scholar
  34. 34.
    Bilimoria MM, Cormier JN, Mun Y, Lee JE, Evans DB, Pisters PWT. Pancreatic leak after pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003;90:190–196.PubMedCrossRefGoogle Scholar
  35. 35.
    Takenchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, Nakajima H, Kuwano H. Distal pancreatectomy: Is staple closure beneficial? Aust N Z J Surg 2003;73:922–925.CrossRefGoogle Scholar
  36. 36.
    Knaebel HP, Diener MK, Wente MN, Buchler MW, Seiler CM. Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005;92:539–546.PubMedCrossRefGoogle Scholar
  37. 37.
    Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernández del Castillo C. Ten-years experience with 733 pancreatic resections: Changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136:391–398.PubMedCrossRefGoogle Scholar
  38. 38.
    Kiely JM, Nakeeb A, Komorowski RA, Wilson SD, Pitt HA. Cystic pancreatic neoplasms: Enucleate or resect? J Gastrointest Surg 2003;7:890–897.PubMedCrossRefGoogle Scholar
  39. 39.
    Fernández-Cruz L, Blanco L, Cosa R, Rendón H, Astudillo E. Is laparoscopic approach an adequate procedure in patients with bening-appearing and overt malignant neuroendocrine pancreàtic tumors? World J Surg (in press).Google Scholar
  40. 40.
    Tseng JF, Warshaw AL, Sahani D, Lauwers GL, Rattner DW, Fernández-del Castillo C. Serous cystadenoma of the pancreas. Tumor growth rates and recommendation for treatment. Ann Surg 2005;242:413–421.PubMedGoogle Scholar
  41. 41.
    Sarr MG, Carpenter, HA, Prabhakar LP, Orchard TF, Hughes S, van Heerden JA, DiMagno EP. Clinical and pathologic correlation of 84 mucinous cystic neoplasms of the pancreas: Can one reliably differentiate benign from malignant (or premalignant) neoplasms? Ann Surg 2000;231:205–212.PubMedCrossRefGoogle Scholar
  42. 42.
    Sarr MG, Murr M, Smyrk C, Yeo CJ, Fernandez del Castillo C, Hawes RH, Freeny PC. Primary cystic neoplasms of the pancreas. Neoplastic disorders of emerging importance-current state-of-the-art and unanswered questions. J Gastrointest Surg 2003;7:417–428.PubMedCrossRefGoogle Scholar
  43. 43.
    Sakorafas GH, Sarr MG. Cystic neoplasms of the pancreas: What a clinician should know. Cancer Treat Rev 2005;31:507–535.PubMedCrossRefGoogle Scholar
  44. 44.
    Lai ECH, Lau WY. Intraductal papillary mucinous neoplasms of the pancreas. Surgeon 2005;5:317–324.CrossRefGoogle Scholar
  45. 45.
    Jiménez RE, Warshaw AL, Z’graggen K, Hartwig W, Taylor D, Compton C, Fernández del Castillo C. Sequential accumulation of K-ras mutations and p53 overexpression in the progression of pancreatic mucinous cystic neoplasms to malignancy. Ann Surg 1999;230:501–511.PubMedCrossRefGoogle Scholar
  46. 46.
    Fabre JM, Houry S, Manderscheid JC, Huguier M, Baumel H. Surgery for left-sided pancreatic cancer. Br J Surg 1996;83:1065–1070.PubMedCrossRefGoogle Scholar
  47. 47.
    Howard TJ, Krug JE, Yu J, Zyromski NJ, Schmidt CM, Jacobson LF, Madura JA, Wiebke EA, Lillemoe KD. A margin negative Ro resection accomplished with minimal postoperative complications. Is the surgeon’s contribution to long-term survival in pancreatic cancer. J Gastrointest Surg 2006;10:1338–1346.PubMedCrossRefGoogle Scholar
  48. 48.
    Shoup M, Conlon KC, Klimstra D, Brennan MF. Is extendet resection for adenocarcinoma of the body or tail of the pancreas justified? J Gastrointest Surg 2003;7:946–952.PubMedCrossRefGoogle Scholar
  49. 49.
    Christein JD, Kendrick ML, Iqbal CW, Nagorney DM, Farneil MB. Distal pancreatectomy for resectable adenocarcinoma of the body and tail of the pancreas. J Gastrointest Surg 2005;9:922–927.PubMedCrossRefGoogle Scholar
  50. 50.
    Shimada K, Sakamoto Y, Sano T, Kosuge T. Prognostic factors after distal pancreatectomy with extended lymphadenectomy for invasive pancreatic adenocarcinoma of the body and tail. Surgery 2006;139:288–295.PubMedCrossRefGoogle Scholar
  51. 51.
    Z’graggen K, Centeno BA, Fernández-del-castillo C, Jimenez AE, Werner J, Warshaw AL. Biological implication of tumor cells in blood and bone marrow of pancreatic cancer patients. Surgery 2001;129:537–546.PubMedCrossRefGoogle Scholar
  52. 52.
    Traverso LW. Pancreatic cancer: Surgery alone is not sufficient. Surg Endosc 2006;S446–S449.Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  • Laureano Fernández-Cruz
    • 1
    • 3
    Email author
  • Rebeca Cosa
    • 1
  • Laia Blanco
    • 1
  • Sammy Levi
    • 1
  • Miguel-Angel López-Boado
    • 1
  • Salvador Navarro
    • 2
  1. 1.Surgical DepartmentICMD Hospital Clínic de BarcelonaBarcelonaSpain
  2. 2.Gastroenterology DepartmentICMD Hospital Clínic de BarcelonaBarcelonaSpain
  3. 3.Department of SurgeryUniversity of Barcelona, Hospital ClínicBarcelonaSpain

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