Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach

Julie Hallet, MD, FRCSC, Daniel Abramowitz, MD, Matt Strickland, MD, Veronica Liang, MD, Calvin Law, MD, MPH, FRCSC, Shiva Jayaraman, MD, MESc, FRCSC. Sunnybrook Health Sciences Center – The Odette Cancer Center, Toronto, Ontario; St-Joseph’s Health Center, Toronto, Ontario; Division of General Surgery, University of Toronto, Toronto, Ontario.

Introduction/Objective: We sought to compare the outcomes of lateral laparoscopic distal pancreatectomy (LLDP) to medial laparoscopic distal pancreatectomy (MLDP). Laparosocopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. The traditional medial approach involves medial division of the gland followed by medial to lateral mobilization. To facilitate dissection and spleen-preservation when applicable, technical reports of a lateral approach whereby lateral mobilization is performed prior to transection have recently surfaced. This offers easier access and precise dissection for distal pancreatic tumors. However, data on this technique remain sparse and inconclusive as it has been reported in only three studies with 1, 4 and 8-patient cohorts. Moreover, it has never been compared to the traditional approach.

Methods and Procedures: We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at 2 hospitals at the University of Toronto, from July 2009 to June 2013. LLDP was performed with the patient in the right lateral decubitus position. After division of the lateral splenic ligaments, the pancreas is elevated from the retroperitoneum from lateral to medial. For this study, primary outcomes were operating time and estimated blood loss. Secondary outcomes were success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, and 30-day major morbidity (Clavien-Dindo grade 3, 4 and 5). We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher exact test for categorical variables, and Mann-Whitney U test for continuous variables.

Results: We retrieved 43 cases (19 LLDP, 24 MLDP). Four conversions occurred with MLDP as opposed to 1 with LLDP (p 0.36). Median operative time was shorter with LLDP (166 Vs. 190 minutes; p 0.03). Median blood loss was lower with LLDP (50 Vs. 250 mL; p <0.01). The proportion of spleen preservation procedures did not differ significantly (p 0.63). All margins were negative with LLDP compared to 2 positive margins (8.3%) with MLDP. There was no difference in the median length of resected pancreatic parenchyma (LLDP 6.9 cm Vs. MLDP 7.1 cm; p 0.70). We observed a trend towards shorter median length of stay with LLDP (4 Vs. 5 days; p 0.35). Major morbidity did not differ (LLDP 21.0% Vs. MLDP 25.0%; p 0.76).

Conclusion: Our initial experience indicates that LLDP is a safe approach for distal lesions of the pancreatic tail and is associated with shorter operative time and decreased blood loss compared to traditional MLDP. Even though our small sample size could not reach statistical significance, observed trends highlight that LLDP may be associated with a decrease length of hospitalization. These hypotheses need to be confirmed on larger cohorts. LLDP is a safe and effective approach to lesions located in the distal body and tail of the pancreas.