The lesson learned in 20 years of minimally invasive distal pancreatectomy: Techniques and results in 282 consecutive procedures.

Background: Minimally invasive distal pancreatectomy (MIDP) has gained a paramount importance in pancreatic tumor resection over the last 20 years. The aim of the present study is to elucidate the evolution of surgical techniques and results in a high volume pancreatic surgery center. Materials and Methods: In the period between January 1999 to December 2018 all Patients undergone to MIDP in Verona University-The Pancreas Institute and Pederzoli Hospital-Peschiera del Garda (since September 2015), are included in the present series. Data prospectively collected are analysed in a retrospective design with particular focus on changes in surgical techniques. Postoperative complications within 90 days from resection were scored according to Modified Accordion Severity Grading System. POPF was defined according to the 2016 ISGPS classification. Results: 282 consecutive MIDP are analysed (202 female, 80 male median age 49); 207 were laparoscopic MIDP and 75 robotic (27%); conversion rate was 7%. 88 had spleen preservation (31%). Pancreatic transection was done by stapler in 166 (59%), harmonic 100 (35%), others techniques 16 (6%). CR-POPF developed in 56 Patients (20%), 5 grade C. 23 Patients were re-operated on (8%), 12 with minimally invasive approach. Mortality was nil. Median Hospital stay was 7 days. There were 144 cystic tumors (51%); 83 Neuroendocrine tumors (29,5%); 36 Ductal Adenocarcinomas (12,8%); 19 Others (6,7%). Conclusion: MIDP is a safe and feasible operation and has becoming the gold standard to remove distal pancreatic tumors. During the study period we changed the indications (more PDAC less cystic), we tried new transection method (from stapler to harmonic), we started the robotic era (2011) with more difficult operations done (RAMPS resections) and we involved many staff surgeons as operators. The postoperative complications and hospital stay are similar during the entire period because of the widening of indications and learning curves of younger surgeons.