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Minimally invasive pancreatectomy (MIP)

Minimally invasive pancreatectomy (MIP)
Literature review current through: Jan 2024.
This topic last updated: Nov 23, 2022.

INTRODUCTION — Minimally invasive pancreatectomy (MIP) can be performed using laparoscopic, robotic, or hybrid techniques. Compared with open surgery, it holds potential advantages for perioperative outcomes and cosmesis. Whereas laparoscopic distal pancreatectomy has been widely accepted in many countries, laparoscopic pancreaticoduodenectomy (Whipple procedure) and robotic MIP procedures are less commonly performed [1].

In this topic, we review the indications, patient selection, procedure selection, surgical techniques, learning curve estimates, and outcomes of MIP. Other aspects of pancreatectomy, notably preoperative determination of resectability and open techniques, are discussed in other topics. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis" and "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas".)

INDICATIONS — MIP is generally performed for the same indications as open pancreatectomy (see "Pathology of exocrine pancreatic neoplasms"):

The most common indications are malignancy, such as pancreatic adenocarcinoma, pancreatic neuroendocrine carcinoma, solid pseudopapillary tumor, bile duct cholangiocarcinoma, or ampullary carcinoma.

The most common benign indication is potentially premalignant pancreatic cystic lesions, such as intraductal papillary mucinous neoplasm (IPMN) [2] or mucinous cystic neoplasm (MCN). Chronic pancreatitis is another benign indication. Importantly, the ability to perform MIP should not lower the threshold for resecting benign pancreatic disease.

PATIENT SELECTION — Patients, especially those with malignant disease, should first undergo evaluation to determine if they are candidates for any surgical resection. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis".)

For patients with resectable disease, there are no absolute contraindications to MIP; relative contraindications include:

Prior open surgery in the upper abdomen and/or prior bariatric procedures (in particular, gastric bypass).

Severe cardiopulmonary disease (eg, reduced cardiac ejection fraction or aortic stenosis), which may limit safe pneumoperitoneum.

Portal vein/superior mesenteric vein involvement is a relative contraindication depending on surgeon experience, whereas hepatic, celiac, or superior mesenteric artery involvement is considered locally advanced and unresectable by current guidelines, and this applies to open pancreatectomy or MIP. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis", section on 'Vascular resection'.)

GENERAL TECHNIQUES — The following steps apply to all MIP procedures. Specific techniques unique to distal pancreatectomy or pancreaticoduodenectomy will be discussed in the next section. (See 'Specific techniques' below.)

Preoperative preparation — We routinely send patients for major abdominal operations, including MIP, to a preoperative evaluation clinic for assessment by our anesthesiology colleagues and other specialists if needed. (See "Preoperative evaluation for anesthesia for noncardiac surgery".)

An enhanced recovery after surgery (ERAS) protocol is followed as we believe the greatest benefits to MIP are realized when an ERAS program is incorporated [3].

Position, lines, and tubes — After intubation and placement of additional peripheral intravenous lines, and arterial line if needed, we place the patient in the supine position on a split leg table. All bony prominences are padded, and the upper chest and legs are strapped. The lower chest and entire abdomen are widely prepped and sterile drapes applied. The bed is then tilted between 10 to 15 degrees for reverse Trendelenburg and 3 to 5 degrees right side up for pancreaticoduodenectomy or left side up for distal pancreatectomy.

A Foley catheter is placed. An orogastric tube is placed after intubation and removed prior to extubation for distal pancreatectomy and just prior to division of the stomach for pancreaticoduodenectomy. We do not routinely use nasogastric tubes; others may prefer a nasogastric tube for pancreaticoduodenectomy.

Peritoneal access — We gain initial entry into the abdominal entry at the Palmer's point using an optical trocar. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Lateral abdomen/flank' and "Abdominal access techniques used in laparoscopic surgery", section on 'Visual entry technique'.)

The abdomen is insufflated with carbon dioxide to a pressure of 15 mmHg. Additional laparoscopic or robotic trocars are then placed under direct vision according to the procedure; trocar positions may need to be adjusted based on tumor location and patient body habitus. (See 'Specific techniques' below.)

Laparoscopic and ultrasound exploration — The operation begins with initial laparoscopic assessment of the bilobar liver surfaces and visible peritoneal lining for occult metastatic disease. Nodules or masses concerning for metastatic disease should be biopsied and frozen section analysis done prior to proceeding with MIP.

Patients requiring pancreatectomy may develop liver fibrosis or cirrhosis as a result of comorbid medical conditions or preoperative systemic chemotherapy.

The finding of advanced cirrhosis preoperatively based on imaging and laboratory studies may preclude safe pancreatectomy.

If unexpected cirrhosis is found intraoperatively, it is not an absolute contraindication to operation. Instead, the surgeon should reevaluate the patient's risk of operative mortality and the indication for operation. For instance, a surgeon may choose to proceed in the setting of invasive cancer but stop an operation for an indication such as mucinous pancreatic cystic lesion with operative intent to prevent future cancer.

Liver ultrasound is reasonable to evaluate for liver parenchymal metastases; however, this is not required if preoperative imaging is high quality and without concern. The authors use laparoscopic liver ultrasound at the beginning of MIP only for situations in which preoperative imaging identified possible liver metastasis for which percutaneous biopsy is not feasible. This situation is rare.

Laparoscopic or robotic ultrasound can localize pathology in the body or tail of the pancreas to guide dissection and location of parenchymal division for distal pancreatectomy. (See 'Laparoscopic distal pancreatectomy and splenectomy' below.)

Liver retraction — For MIP, it is often necessary to retract the central liver and left lateral segment to facilitate dissection. An articulating liver retractor is placed through a 5 mm trocar in the lateral left or right abdomen. A stainless steel retractor such as the Nathanson device is an alternative placed directly through the abdominal wall in the upper midline (epigastric) after creating a tract using a 5 mm trocar. Both types of retractors are held in place after positioning using a mechanical clamp and arm secured to the bed.

Specimen extraction and closing — We place an impermeable bag through one of the larger trocars for specimen removal. The specimen is placed in the bag and the trocar removed after bag ties are brought out through the trocar. The incision is extended until the bag can be pulled from the abdominal cavity. For robotic procedures, the robot is undocked prior to specimen extraction so that the ports do not pull out when pneumoperitoneum is lost. Port sites >5 mm are closed at the fascial level (see "Abdominal access techniques used in laparoscopic surgery", section on 'Fascial closure'). Absorbable monofilament suture is used for all skin closure.

Anticipating intraoperative complications — Any experienced pancreatic surgeon will affirm that staying out of trouble is preferred to getting out of trouble. That said, both are necessary in pancreatectomy.

Aberrant arterial anatomy – Dedicated review of preoperative imaging by the surgeon is imperative to discern alternate vascular anatomy. In particular, a replaced right hepatic artery is prone to inadvertent injury if not identified preoperatively. MIP approaches remain feasible in the setting of aberrant arterial anatomy [4].

Vascular involvement – Due to the inability to palpate the anatomic relationship of the tumor to the mesenteric vessels during the MIP approach, there is increased emphasis on judicious review of high-quality pancreas protocol cross-sectional imaging to anticipate vascular involvement preoperatively.

In cases of suspected portal or superior mesenteric vein involvement, we have several curved and straight laparoscopic bulldog vascular clamps available on the operative field. We also have several 4-0 monofilament permanent sutures loaded and cut to a length of four to six inches in this situation. Finally, we crossmatch for four units of packed red blood cells prior to operation, and we have two of these units brought to the operating room if vein abutment or invasion is identified during dissection. Being prepared for the need for rapid conversion to open is necessary; therefore, we ensure availability of an open retraction system and hand-assist port prior to starting the case.

Postoperative complications — Management of postoperative complications after MIP is the same as for patients after open pancreatectomy. (See "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas".)

SPECIFIC TECHNIQUES — MIP can be performed using purely laparoscopic or robotic techniques or hybrid or hand-assisted approaches. The choice depends primarily on the training and experience of the surgeon. Patient factors such as body habitus and tumor factors such as tumor location or presence of vascular invasion may also influence the decision. For example, the robotic approach can be challenging in very thin patients due to the need for lateral spread of the trocars.

Division of the pancreas at the neck or slightly to the right of the neck is the medial limit for distal pancreatectomy. If the target lesion lies further to the right of that limit or involves the gastroduodenal artery, pancreaticoduodenectomy or total pancreatectomy is likely needed. The following steps are unique to either distal pancreatectomy or pancreaticoduodenectomy. General techniques common to all pancreatectomies have been discussed previously. (See 'General techniques' above.)

Distal pancreatectomy — There is an ongoing debate about the potential benefits of spleen preservation with distal pancreatectomy [5]. Studies suggest that rates of splenic preservation are higher with a laparoscopic or robotic approach than with open surgery [6].

Laparoscopic distal pancreatectomy and splenectomy — The basic steps of operation are listed below in the usual order of events. Patient or tumor factors may require modification of this order or the details of each step. During the course of dissection, vessel loops are often helpful for retraction of vascular structures prior to division. Curved-tip staplers are also very helpful to pass around the vessel without injury.

Access and insufflate the peritoneal cavity followed by trocar placement (figure 1).

Place a retractor to lift the left lateral segment of the liver (segments 2 and 3). (See 'Liver retraction' above.)

Enter the lesser sac through the greater omentum and divide attachments between the pancreas and posterior stomach.

Perform an ultrasound of the pancreas body and tail if the target lesion is not visible or if there is concern for pancreas parenchyma involvement at the level of the planned division. (See 'Laparoscopic and ultrasound exploration' above.)

Divide the greater omentum, including all short gastric vessels, to the level of the left crus of the diaphragm using electrocautery and a bipolar vessel-sealing device. (See "Instruments and devices used in laparoscopic surgery", section on 'Devices for hemostasis'.)

Most surgeons advocate preservation of short gastric vessels if splenic preservation is planned. It may be necessary to divide some of the short gastric vessels to gain proper exposure and facilitate safe retraction of the stomach.

Move the liver retractor to lift the stomach and left lateral segment of the liver together.

Dissect circumferentially around the pancreas, splenic artery, and splenic vein at the area of planned division. These are typically avascular planes.

Divide the splenic artery and splenic vein with a vascular stapler and the pancreas parenchyma with an appropriate-thickness stapler load (with or without reinforcement material). (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Pancreatic transection and closure'.)

Divide the remaining retroperitoneal attachments to the body and tail of the gland and ligamentous connections between the spleen and left diaphragm using a bipolar vessel-sealing device.

It is also possible to mobilize the spleen and body/tail of the pancreas prior to division of the gland and splenic vessels. The choice of either technique depends on patient and tumor anatomy and which portions of the dissection may be more challenging. In general, we perform the easier parts of the dissection earlier to facilitate exposure to the more difficult areas.

Extract the specimen using an impermeable bag. (See 'Specimen extraction and closing' above.)

Leave a closed suction drain if desired along the stapled edge of the pancreas.

Robotic distal pancreatectomy and splenectomy — For the robotic approach, both robotic and laparoscopic trocars can be used. The steps of the operation are similar to those of the laparoscopic approach described above (figure 2).

The robot vessel-sealing device and robot staplers may be operated by the surgeon from the robot console, or an experienced bedside assistant may use a conventional laparoscopic stapler and vessel-sealing device. Laparoscopic ultrasound is available to be used with the robot platform with dual display of the ultrasound view and the operative field at the robot console.

Pancreaticoduodenectomy

Laparoscopic pancreaticoduodenectomy — Laparoscopic pancreaticoduodenectomy is not commonly performed, and there are relatively few series in the literature. At high-volume centers with experienced surgeons, laparoscopic pancreaticoduodenectomy is feasible and safe [7,8]. Despite this, many surgeons prefer an open approach due to the complexity and length of the operation. In addition, many surgeons are not experienced with laparoscopic intracorporeal suturing, and the requirement for three anastomoses is another impediment to adoption of laparoscopic pancreaticoduodenectomy. The robotic platform offers a potentially shorter learning curve for minimally invasive suturing. For these and other reasons, we prefer the robotic approach to pancreaticoduodenectomy and will therefore provide more technical details for that operation below.

Robotic pancreaticoduodenectomy — The authors prefer a robotic approach for minimally invasive pancreaticoduodenectomy. The basic steps of the operation are listed below in the usual order of events (figure 3). Patient or tumor factors may require modification of the order or details of each step.

This list describes the steps for a straightforward pancreaticoduodenectomy without venous or arterial resection. During the course of dissection, vessel loops are often helpful for retraction of vascular structures prior to division. Curved-tip staplers are also very useful to pass around the vessel without injury. (See 'Anticipating intraoperative complications' above.)

It is important to state that some early steps commit the surgeon to completion of the operation, such as dividing the pancreas or duodenum and its mesentery. Modifying the order of steps may be needed in situations of uncertain resectability.

Access and insufflate the peritoneal cavity followed by trocar placement (figure 3).

Place a retractor to lift the liver at the level of the falciform ligament. (See 'Liver retraction' above.)

Enter the lesser sac through the greater omentum and divide attachments between the pancreas and posterior stomach.

Divide the omentum partially around the greater curve and then toward the hepatic flexure of the colon; do not divide the right gastroepiploic vessels at this time.

Mobilize the hepatic flexure of the colon and divide lateral attachments along the duodenum for a wide Kocher maneuver.

Dissect along the lateral and posterior duodenum, pulling it laterally until the ligament of Treitz tissues are divided. It may also be necessary to divide some Treitz attachments from the other side of the mesentery (picture 1), particularly in patients with prior abdominal surgery.

Pull the jejunum through the retroperitoneal defect and divide the proximal jejunum with a stapler.

Divide the mesentery to the jejunum and duodenum on the specimen side, stopping before the transition to uncinate process attachments; divide the more posterior attachments to the duodenum here if feasible to straighten redundant bowel, which facilitates the uncinate dissection later.

Divide the stomach using a stapler. The authors typically divide the stomach between the midpoint of the greater curve to the midpoint of the lesser curve. Many surgeons prefer to spare the pylorus. For this technique, the proximal duodenum just distal to the pylorus is divided using a stapler, typically after division of the right gastric vessels with an energy device.

At the porta hepatis, remove the hepatic artery lymph node to identify the proper hepatic artery and gastroduodenal artery. If the hepatic artery node is not visualized, a safe location to start dissection is the anterior and left porta hepatis to find the hepatic artery at that location.

Divide the gastroduodenal artery with a vascular stapler (picture 2).

Identify the portal vein medial to the bile duct and divide the bile duct with a vascular stapler. In patients with alternate hepatic arterial anatomy, especially replaced right hepatic artery, we sometimes divide the bile duct with monopolar cautery to be sure we do not injure the artery or include it in the stapler.

Separate the portal vein from the superior neck of the pancreas.

Identify the superior mesenteric vein (SMV) at the inferior neck and pass a blunt instrument under the neck of the pancreas over the vein (picture 3).

Divide the neck of the pancreas with monopolar cautery; divide the pancreas duct sharply.

Dissect anterior to the distal SMV until identification of the right gastroepiploic vein origin and first jejunal branch; divide the inferior attachments between the uncinate process and superior mesenteric artery with superior retraction of the specimen (picture 4).

Divide the superior attachments between the uncinate process of the pancreas and the superior mesenteric artery; grasp the specimen end of the divided bile duct and retract specimens inferiorly for this step (picture 5).

Complete the cholecystectomy.

Place specimens inside an impermeable bag, then extend the incision for a 15 mm trocar to extract. (See 'Specimen extraction and closing' above.)

Place a gel port through the extended incision, then a 15 mm trocar through the gel rubber portion.

Start the pancreatojejunostomy anastomosis using interrupted 2-0 silk sutures passed through the pancreas gland and sewn to the seromuscular layer on the posterior side of the divided jejunum; the inner layer is duct-to-mucosa interrupted 5-0 monofilament absorbable sutures followed by completion of outer-layer sewing silk sutures to the seromuscular layer of the anterior bowel (picture 6).

A hepaticojejunostomy anastomosis is created to the same loop of divided jejunum using either interrupted 5-0 monofilament absorbable sutures or running 4-0 locking absorbable suture (picture 7).

The authors leave a 4 or 5 French small plastic stent across the pancreatojejunostomy anastomosis and selectively for small hepaticojejunostomy anastomoses.

The jejunum around 50 to 60 cm distal to the hepaticojejunostomy anastomosis is marked with a silk suture to ensure proper orientation for the gastrojejunostomy.

Gastrojejunostomy anastomosis is stapled side to side, antecolic, and retrogastric with the common enterotomy oversewn using single-layer running locking 3-0 absorbable suture. If pylorus preservation is chosen, the anastomosis is created using two layers of running 3-0 absorbable suture (picture 8).

Leave a closed suction drain anterior to the anastomoses.

Other pancreatectomy procedures — Less common pancreatic resectional operations are also feasible with a minimally invasive approach:

Central or middle pancreatectomy is an alternative to distal pancreatectomy for tumors or other pathology in the neck or medial body of the gland. The operation involves removing the central portion of the gland by dividing the pancreas at the neck and again to the left of the pathologic lesion somewhere in the distal body or tail. A Roux-en-Y pancreatojejunostomy anastomosis is then done to the divided distal pancreas. This operation is possible with a laparoscopic or robotic approach [9,10].

Enucleation of pancreatic neuroendocrine tumors is an ideal application of MIP and has been described using the robotic approach [11].

Complex pancreatic resections involving vascular resection are also described using either a laparoscopic or robotic approach [12].

OUTCOMES

Open versus MIP

Distal pancreatectomy — Most observational studies have associated laparoscopic distal pancreatectomy with less blood loss, fewer transfusions, earlier oral intake, shorter length of hospital stay, and fewer complications compared with open distal pancreatectomy (table 1) [6,13,14]. Operative time is longer with laparoscopic distal pancreatectomy in some studies [15].

For cancer patients, laparoscopic distal pancreatectomy is associated with similar rates of positive margin, nodal harvest, and survival to those of open distal pancreatectomy [16-18]. However, the quality of evidence is low due to potential selection bias against open distal pancreatectomy [19].

The LEOPARD trial was a multicenter patient-blinded trial comparing minimally invasive distal pancreatectomy with open distal pancreatectomy for benign, premalignant, and malignant indications [20]. Most of the minimally invasive cases were laparoscopic (n = 42, 89 percent) with only a small number done robotically (n = 5). The conversion rate was 8 percent (n = 4), and operative time was longer for the minimally invasive group (median 217 versus 179 minutes). For the cancer cases, margin-positive rates and lymph nodes harvested were similar. Rates of complication were also similar, but time to functional recovery (primary outcome; median four versus six days), blood loss, and length of hospital stay were better in the minimally invasive group.

Compared with open distal pancreatectomy, robotic distal pancreatectomy had similar advantages, such as shorter hospital stay, but a longer operative time [21].

Studies comparing robotic distal pancreatectomy with laparoscopic distal pancreatectomy are conflicting. One meta-analysis found similar rates of conversion, transfusion, and pancreatic fistula and similar operative time [22]. Other studies associated the robotic approach with longer operative time but less blood loss, a higher rate of spleen preservation, a shorter hospital stay, and lower rate of conversion [21,23-27]. Oncologic outcomes (margin-positive cases, lymph node harvest and survival) are similar [28].

In an effort to establish benchmark values for high-quality outcomes related to minimally invasive distal pancreatectomy with splenectomy, 31 European centers studied 1595 patients from 2003 to 2019 using the Achievable Benchmark of Care (ABCs) method. Risk-adjusted ABCs or values representing high quality were a 2.5 percent conversion to open surgery rate, 8.4 percent morbidity rate, 160 minute operative time, 8.3 percent postoperative pancreatic fistula rate, and 0 percent perioperative mortality rate [29]. Further studies such as this one are necessary to define standards for MIP.

Pancreaticoduodenectomy — Most observational studies also associated minimally invasive pancreaticoduodenectomy with longer operative times but shorter hospital stay and less blood loss. Otherwise, complication rates, including pancreatic fistula rates, and oncologic outcomes are similar (table 2) [30-33]. However, the quality of evidence is also low due to potential selection bias in favor of MIP.

The LEOPARD-2 trial randomly assigned 99 patients to laparoscopic or open pancreaticoduodenectomy [34]. The trial was terminated early by the data and safety monitoring board due to a 10 percent (5/50) rate of perioperative mortality in the laparoscopic pancreaticoduodenectomy group compared with 2 percent (1/49) in the open cohort. Overall complication rates, including pancreatic fistula rates, were similar. According to the investigators, the difference in mortality rate was "unexpected and worrisome" since all operations were done at high-volume centers by trained surgeons.

In our opinion, this outcome is concerning but does not indicate we must abandon the practice of minimally invasive pancreaticoduodenectomy, in particular for surgeons using the robotic approach after formal training. In our own initial series of robot pancreaticoduodenectomy, there were zero perioperative deaths in the first 40 operations [35].

Cost effectiveness — Pancreatic resection often requires a variety of costly surgical instruments such as staplers, energy devices, and hemostatic agents. Many assume MIP costs more than open procedures due to the use of more expensive equipment and longer operative time. Proponents of MIP argue that the extra cost may be offset by shorter hospital stay and other benefits.

Cost-effectiveness studies that exist in the literature are heterogeneous in design with contradictory findings [25,36-38]. The aforementioned LEOPARD study deemed MIP cost effective when considering benefits to functional recovery and quality-adjusted life-years [39].

Learning curve — The learning curve for laparoscopic or robotic distal pancreatectomy and pancreaticoduodenectomy is reported to be anywhere from 15 to 80 operations depending on outcomes measured, such as operative time, conversion rate, blood loss, and pancreatic leak rate [40-43].

Operative time is perhaps the most widely accepted measure of the learning curve, and longer operative time is associated with a higher rate of complications and longer hospital stay for both distal pancreatectomy and pancreaticoduodenectomy, independent of preoperative patient characteristics [44]. For robotic pancreaticoduodenectomy, more cases are required to achieve a consistent operative time (80 cases) than a consistent pancreatic fistula rate (40 cases) and conversion rate (20 cases) [41].

Formal training programs for MIP are increasingly used by surgeons who wish to add these operations to their practice. In the Netherlands, surgeons at 17 centers participated in a nationwide training program for minimally invasive distal pancreatectomy including detailed technique description, video training, and proctoring on site from 2014 to 2015. When outcomes were compared from periods before and after training, there was a sevenfold increase in the use of minimally invasive distal pancreatectomy with decreases in conversion rate (38 versus 8 percent), blood loss, and length of hospital stay [45]. Complication rates were similar.

The rate of conversion from MIP to open pancreatectomy varies by procedure and institution. Risk factors for conversion include malignant indication and need for multiorgan resection; the surgeon's learning curve is also a factor [40]. Patients who are not candidates for open abdominal operation should not undergo MIP either, as conversion may be necessary.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pancreatic cancer" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

Indications and patient selection – Minimally invasive pancreatectomy (MIP) is performed for the same indications as open pancreatectomy. Patients must first be evaluated for resectability of their diseases. For those with resectable disease, there are no absolute contraindications to MIP; relative contraindications include prior upper abdominal open surgery or bariatric surgery, severe cardiopulmonary disease limiting safe pneumoperitoneum, and vascular invasion (depending on surgeon experience). (See 'Indications' above and 'Patient selection' above.)

Minimally invasive distal pancreatectomy – Minimally invasive distal pancreatectomy has perioperative and oncologic outcomes that are comparable to those of open surgery and potential advantages in length of stay, blood loss, and patient functional recovery. Distal pancreatectomy with splenectomy can be performed using laparoscopic, robotic, or hybrid approaches. All minimally invasive approaches are reasonable options, and the choice is largely based on surgeon training and experience. Limited data suggest similar outcomes among the procedures. (See 'Distal pancreatectomy' above.)

Minimally invasive pancreaticoduodenectomy – Minimally invasive pancreaticoduodenectomy requires further study since the LEOPARD-2 trial reported a concerning increase in mortality with laparoscopic compared with open pancreaticoduodenectomy. (See 'Pancreaticoduodenectomy' above.)

Cost effectiveness – MIP may be cost effective at high-volume centers. The extra cost of equipment and longer operative time associated with MIP may be offset by a shorter hospital stay and other benefits. (See 'Cost effectiveness' above.)

Learning curve – Formal training is a critical aspect for safe adoption of MIP by any surgeon. The reported learning curve for MIP ranges anywhere from 15 to 80 operations depending on the procedure and outcomes measured. (See 'Learning curve' above.)

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Topic 127000 Version 4.0

References

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