title: Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach.
abstract: BACKGROUND
  Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP.
  
  
  METHODS
  We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables.
  
  
  RESULTS
  We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant.
  
  
  CONCLUSIONS
  LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.
authors.affiliation: Division of General Surgery, University of Toronto, Toronto, ON, Canada, matt.strickland@utoronto.ca.
authors.forename: Matt
authors.initials: M
authors.lastname: Strickland
authors.forename: Julie
authors.initials: J
authors.lastname: Hallet
authors.forename: Daniel
authors.initials: D
authors.lastname: Abramowitz
authors.forename: Shuyin
authors.initials: S
authors.lastname: Liang
authors.forename: Calvin H L
authors.initials: CH
authors.lastname: Law
authors.forename: Shiva
authors.initials: S
authors.lastname: Jayaraman
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010180:Pancreatectomy / Q000379:methods*; D010182:Pancreatic Diseases / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome