Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: A meta-analysis

Table 1 Database and search strategy

Database	Search strategy
PubMed	"laparoscopy" (MeSH terms) or "laparoscopy" (all fields) or "laparoscopic" (all fields) or (minimally (all fields) and invasive (all fields) and ("pancreas" (MeSH terms) or "pancreas" (all fields) or "pancreatic" (all fields) and "humans" (MeSH terms) and English (lang) and "1995/1/1" (PDAT): "2011/06/30" (PDAT)
Web of Science	"pancreas" or "pancreatic" or "pancreatectomy" and "laparoscopy" or "laparoscopic" (limited year: 1995-2011)
Cochrane Library	"pancreas" or "pancreatic" or "pancreatectomy" and "laparoscopy" or "laparoscopic" (limited year: 1995-2011)
BIOSIS Previews	"pancreas" or "pancreatic" or "pancreatectomy" and "laparoscopy" or "laparoscopic" (limited year: 1995-2011) (related term and limited English and human and year: 1995-2011)

PDAT: Pulication date; MeSH: Medical subject headings.

Table 2 Characteristics of the literatures

Ref.	Study year	Nation	Case number		Study type	Pancreatictransection		Spleen persevation		Totalmorbidity		PF		Mortality %		Level of evidence
			LDP	ODP		LDP	ODP	LDP	ODP	LDP	ODP	LDP	ODP	LDP	ODP
Aly et al[23]	1998-2009	Japan	40	35	Retro	Stapler	Stapler/scalpel + suture	13	3	8	11	5	6	0	0	4
Baker et al[24]	2003-2008	USA	27	85	Pros	Stapler/ scalpel + micro sealer device	Scalpel + suture	NA		10	30	6	12	0	0	2b
Butturini et al[25]	1999-2006	Italy	43	73	Retro	Stapler	Scalpel + suture	19	8	21	33	12	10	0	0	2b
Casadei et al[26]	2000-2010	Italy	22	22	Case control	Stapler	Stapler	NA		6	6	2	4	0	0	2b
DiNorcia et al[27]	1991-2009	USA	71	192	Retro	Stapler	Stapler/ Scalpel + suture	11	30	20	84	8	27	0	2	4
Eom et al[28]	1995-2006	Korea	31	62	Retro	Stapler	Scalpel + suture	13	NA	11	15	3	4	0	0	4
Jayaraman et al[29]	2003-2009	USA	74	236	Retro	Stapler/ scalpel + suture	Stapler/ scalpel + suture	14	33	11	94	6	31	NA		4
Kim et al[30]	NA	Korea	93	35	Retro	Stapler	Stapler/ Scalpel + suture	38	2	23	11	8	5	NA		4
Vijan et al[31]	2004-2009	USA	100	100	Retro	Stapler	NA	25	NA	34	29	17	17	3	1	4

Retro: Retrospective observational study; Pros: Prospective observational study; LDP: Laparoscopic distal pancreatectomy; ODP: Open distal pancreatectomy; PF: Pancreatic fistula; NA: Not available.

Table 3 Technical details of spleen-preservation

Ref.	Spleen preserving %		Technical details
	LDP	ODP
Aly et al[23]	32.5	8.6	Both procedures, spleen vessel ligation were performed, leaving the short gastric vessels to supply the spleen (Warshaw)
Baker et al[24]	NA		In ODP, the benign and premalignant pathology, the spleen was routinely saved by means of the splenic vein and artery preserved
			In LDP, splenic salvage by means of Warshaw: ligating the splenic artery and vein but preserve the short gastric vessel
Butturini et al[25]	44.2	11.0	Both procedures, exposing the splenic vein up to the splenic hilum; the distal pancreas was detached from the splenic artery in the opposite direction by tractioning the parenchyma
Casadei et al[26]	NA		Mobilization of the distal pancreas from retroperitoneum and splenic vessels
DiNorcia et al[27]	15.5	15.6	For spleen preserving distal pancreatectomy, an attempt to spare the splenic artery and vein was made in all patients
Eom et al[28]	41.9	NA	For spleen preserving distal pancreatectomy, both the splenic artery and vein were preserved
Jayaraman et al[29]	18.9	14.0	When splenic preservation was performed, the splenic vein and artery were isolated
Kim et al[30]	40.9	5.70	In spleen preserving distal pancreatectomy, both the splenic artery and vein were preserved. In one case, the splenic artery was ligated with preservation of splenic vein. In the other case, both the splenic artery and vein were ligated, with preservation of short gastric vessels (Warshaw)
Vijan et al[31]	25	NA	If splenic preservation is indicated, the pancreas is dissected off the splenic vessels

LDP: Laparoscopic distal pancreatectomy; ODP: Open distal pancreatectomy; NA: Not available.

Table 4 Technique of pancreatic stump closure

Ref.		Technique description
Aly et al[23]	LDP	The pancreatic parenchyma was transected using a laparoscopic linear stapler
	ODP	The pancreatic parenchyma was transected using a scalpel, and the main pancreatic duct was ligated using nonabsorbable sutures. The pancreatic stump was closed with fish-mouth sutures. A linear stapler was used to transect the pancreatic parenchyma
Baker et al[24]	LDP	The gland was divided by one of 3 mechanisms: vascular stapler, harmonic scalpel, or harmonic scalpel following ablation at the pancreatic resection margin with the Habib 4*3 microsealer device
	ODP	Directly ligate the pancreatic duct when visible with a monofilament absorbable suture. The neck of the gland was oversewn with nonabsorbable monofilament suture
Butturini et al[25]	LDP	The pancreatic body was transected by a linear endostapler
	ODP	Pancreatic parenchyma was sharply transected. The main pancreatic duct was closed with nonabsorbable sutures (polypropylene 4/0). Subsequently the pancreatic stump was oversewn with interrupted mattress nonabsorbable sutures or closed using a linear stapler
Casadei et al[26]	LDP	The pancreas was divided at the neck using an endo-GIA instrument
	ODP	The pancreas was divided using GIA 55
DiNorcia et al[27]	LDP	Sutures, staples, sutures and staples combined, or staples with bioabsorbable staple-line reinforcement
	ODP
Eom et al[28]	LDP	The pancreas was transected using the 48- or 35-mm vascular endoscopic linear stapler
	ODP	The pancreatic parenchyma was divided using a blade and electrocautery. The main pancreatic duct was ligated with nonabsorbable sutures, and the transected pancreas was occluded with interlocking interrupted mattress sutures of 4-0 black silk and reinforced with 4-0 polypropylene
Jayaraman et al[29]	LDP	The pancreas was stapled using a vascular stapler with or without a Seamguard attachment
	ODP	Ligate pancreas with staples, or via suture ligation, or a combination of techniques
Kim et al[30]	LDP	For pancreatic transaction, straight endoscopic linear staplers of various sizes (staple height, 3.5-4.2 mm) were used according to the thickness or hardness of the pancreas. Four or five small titanium clips were applied along the stapling line
	ODP	The pancreatic stump underwent main duct ligation, multiple suture ligation of the branch duct exposed at the resection margin, and reinforcement of the mattress suture to the pancreas stump
Vijan et al[31]	LDP	The pancreatic parenchyma is divided with the harmonic scalpel (preferred) or with an Endo GIA stapler
	ODP	NA

LDP: Laparoscopic distal pancreatectomy; ODP: Open distal pancreatectomy; NA: Not available; GIA: Gastrointestinal incision anastomose.