The guidelines on minimally invasive pancreas resection (MIPR) were released in January 2020 by the International Study Group on Minimally Invasive Pancreas Surgery (I-MIPS), cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.
Distal and Central Pancreatectomy
Minimally invasive distal pancreatectomy (MIDP) for benign and low-grade malignant tumors is to be considered over open distal pancreatectomy (ODP), in that it is associated with a shorter hospital stay, reduced blood loss, equivalent complication rates, and better postoperative quality of life.
MIDP for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands.
No evidence exists regarding the use of vascular resection in MIDP.
Both stapler and nonstapler closure can be used in MIDP; outcomes are comparable. Evidence to support routine staple-line reinforcement with any method or material is lacking.
No studies exist specifically comparing spleen-preserving MIDP with spleen-preserving ODP.
Both laparoscopic distal pancreatectomy (LDP) and robotic distal pancreatectomy (RDP) are safe and feasible. The choice of technique should be based on surgeons’ experience and local resources.
Minimally invasive central pancreatectomy has been reported to be feasible, but safety must be confirmed before it can be widely adopted. Comparative data on minimally invasive vs open central pancreatectomy are inadequate.
Minimally invasive enucleation of pancreatic lesions in selected patients is an appropriate alternative to open enucleation.
Pancreatoduodenectomy
Insufficient data exist to recommend minimally invasive pancreatoduodenectomy (MIPD) over open pancreatoduodenectomy (OPD). Both MIPD and OPD are valid approaches for selected patients with adenocarcinoma.
No comparative data exist regarding MIPD vs OPD for the treatment of pancreatic head adenocarcinoma after neoadjuvant therapy.
Limited comparative data exist regarding MIPD vs OPD for the treatment of pancreatic head ductal adenocarcinoma requiring vascular resection. MIPD with vascular resection should be performed only by highly experienced surgeons and in high-volume centers.
No evidence of superiority exists regarding laparoscopic pancreatoduodenectomy (LPD) vs robotic pancreatoduodenectomy (RPD) for the treatment of pancreatic head lesions. Surgeon training, experience, and available resources guide the choice of approach.
Patients and Technique
There are no contraindications for MIPR based on patient age, obesity, or previous abdominal surgery.
The evidence to suggest a relationship between comorbidity and the outcome of MIPR is limited.
No evidence exists that specifically addresses the relative benefits of any particular hemostatic technique in MIPR.
No evidence exists to clearly determine the appropriate timing or indication for conversion in MIPR. Elective conversion should be considered on the basis of surgeon experience, concern for patient safety, or failure to progress.
Training and Implementation
Participation in a structured training program is strongly recommended for all surgeons undertaking MIPR.
Single-surgeon learning curves for MIPR show improvements in operative time, blood loss, lymph node harvest, and complications with increased total volume/experience; the exact number remains to be defined.
No specific studies assess prerequisites for MIPR. Experience in pancreatic surgery, including a formal fellowship training or an established practice as a pancreatic surgeon, is advised. A two-surgeon approach can be beneficial in the learning curve.
Center volume strongly affects outcomes after MIPR; consideration of total pancreas resection volume along with MIPR-specific volume is critical. MIPD should be performed in high-volume centers; mortality (at < 10 MIPD/y) and morbidity (at < 20 MIPD/y) are worse in low-volume settings.
Centers undertaking MIPR should consider the following measures: implementing dedicated individual and team training; having more than one surgeon performing MIPR at the institution; monitoring outcomes of MIPR for quality assurance; and considering surgeon/institution volume of pancreas resections, including MIPR.
Instrumentation
No documented advantages for any specific energy device have been reported.
The development of instruments and enhanced visualization systems for MIPR should be encouraged.
Accountability
Inclusion of patient data into thoughtfully organized and maintained regional, national, and international registries supported by hepatopancreatobiliary organizations is strongly encouraged.
Because outcome monitoring of MIPD is essential for its safe and wide expansion, inclusion into validated regional, national, and international registries is highly recommended.
Development and expansion of MIPR should be encouraged and monitored by national and international societies through the promotion of working groups to drive training and registries.
For more information, please go to Laparoscopic Pancreatectomy and Pancreatosplenectomy and Spleen-Preserving Distal Pancreatectomy.
For more Clinical Practice Guidelines, please go to Guidelines.
Source : Medscape