*3.4.2 Outcomes*

*Recent Advances in Laparoscopic Surgery*

The approach in LESS distal pancreatectomy is mostly transumbilical. Occasionally, an additional 5 mm trocar is inserted in the left upper quadrant to be used by the surgeon's right hand and subsequently for drainage [78]. Various modifications of gastric suspension technique have been developed to facilitate better exposure of the pancreas [79–81]. The Lasso technique, in which a ribbon tape is looped around the pancreas body or tail, can be used to provide additional traction, particularly in cases of LESS distal pancreatectomy without splenic preservation [81, 82]. The pancreatic mobilization and dissection follow the principles of standard laparoscopic pancreatic resection, and the resected specimen is extracted through the umbilical site.

In a recent review, Chatzizacharias et al. analysed the data on LESS distal pancreatectomy from eight case studies. Conversion to open rate was 0–19%, and postoperative complications, mainly pancreatic fistula, were reported in 22% (0–50%) of patients. The length of hospital stay ranged between 1 and 15 days [39]. More importantly, Han et al. compared the outcomes between patients undergoing LESS and conventional laparoscopic distal pancreatectomy. With the exception of significantly longer operative time and duration of hospital stay reported with the LESS approach, perioperative outcomes did not differ between the two groups [83]. Likewise, two comparative analyses, including a case-control study, yielded no significant differences between conventional laparoscopic and LESS distal pancreatectomy in the operative time, intraoperative bleeding, conversion rate, resection status, hospital stay, and complications [75, 84]. The spleen was preserved more in the conventional group than in the LESS group, but this difference was not significant [83, 84]. A recent comparison between LESS and the more widely accepted robotic distal pancreatectomy has evidenced a significantly longer operative time and hospital stay, larger intraoperative blood loss, less spleen preservation, and higher grade II/IIIa postoperative complications in the LESS group. There were no significant differences in pain scores, tumour size, conversion rate, and overall complications between the two groups [85]. Overall, although it has been shown to be safe and feasible, these findings highlight the question of any real

value of LESS approach in the context of pancreatic surgery.

disorder, and splenic aneurysms and neoplasms [88].

Despite the scarcity of high-level evidence, there has been a dramatic increase in the number of laparoscopic splenectomies performed over the last 2 decades. The procedure is currently considered the gold standard for management of surgical diseases in normal or slightly enlarged spleens [86]. More recently, and as a bridging procedure towards pure natural orifice transluminal endoscopic surgery, Barbaros and Dinççağ were the first to describe LESS splenectomy in two female patients with idiopathic thrombocytopenic purpura [87]. Other common indications for this approach are splenic cystic disease, hereditary spherocytosis, myeloproliferative

For LESS splenectomy, either a transumbilical or a lateral rectus incision can be utilized depending on the size of spleen. The technique used for splenic

**3.4 LESS splenic surgery**

*3.4.1 Technical considerations*

*3.3.1 Technical considerations*

*3.3.2 Outcomes*

**62**

A systematic review published by Fan et al. summarized the evidence on LESS splenectomy from 29 articles, with a total of 105 patients. The median length of hospital stay varied from 1 to 11 days. The postoperative complication rate was 0–33.3%, and the rates of conversion to open and multiport laparoscopic surgery were 1.9 and 2.9%, respectively. Bleeding from the splenic or short gastric vessels were the main reasons for conversion. No perioperative death was observed [88]. In a comparison between reduced-port, multiport, and LESS splenectomy, Monclova et al. reported significantly longer operative time in the LESS group, and this was partly related to the higher spleen weight. Importantly, there was a significant advantage in the LESS and reduced-port groups in the body image index with respect to the multiport group, pointing to better cosmetic outcome. Other perioperative outcomes were comparable among the two groups [91]. Wu et al. conducted a comprehensive meta-analysis comparing the outcomes of LESS and conventional laparoscopic splenectomies. They pooled and meta-analysed the data of 332 patients from nine comparative and one prospective case-control study. While postoperative pain scores favoured the LESS approach, the conversion rate and operative time slightly favoured conventional laparoscopic surgery, though without statistical significance. Ultimately, no differences were observed with regard to morbidity, mortality, analgesics requirements, and postoperative hospitalization. The authors pointed out that LESS splenectomy is safe and feasible with no obvious advantages over multiport laparoscopic splenectomy [92].
