TABLE 5.

Domain 5 Surgical Techniques and Instrumentation; Questions and Recommendations on Laparoscopic (L), Robotic (R), and General (G) MIPS

Topic 12: Techniques in Distal Pancreatectomy
G26	What is the best approach for the dissection/control of the splenic vessels?	26.1 When appropriate, dissection between the pancreas and splenic vessels should be carefully performed with a combination of blunt dissection and energy devices after complete mobilization of the colonic splenic flexure.	Low	Strong (upgraded by experts)
		26.2 Careful attention should be given to control small arterial and venous branches into the pancreas (with clips and/or energy devices) when splenic vessels need to be preserved.	Low	Strong (upgraded by experts)
		26.3 A tailored approach to the splenic artery should be encouraged according to individual cases and vascular anatomy. Surgeons should be familiar with both the anterior and posterior approaches.	Low	Strong (upgraded by experts)
		26.4 When dividing the pancreas at the level of the neck, clear visualization of the splenic/portal vein junction should be obtained before ligation and division of the splenic vein. When dividing the pancreas to the left of the celiac trunk, the splenic vessels could be individually ligated or incorporated in the pancreatic division according to surgeon preference.	Low	Strong (upgraded by experts)
		26.5 Accurate preoperative planning and revision of imaging are recommended to evaluate the patient’s arterial and venous vascular anatomy to safely approach splenic vessels.	Low	Strong (upgraded by experts)
G27	Is there any indication for a pancreatic hanging maneuver in MIPD	The pancreatic hanging maneuver is an appropriate option during MIDP.	Low	Strong (upgraded by experts)
Topic 13: Surgical Devices
G28	What type of energy and instruments should be used during the dissection phase?	The choice of energy devices and instruments for dissection during MIPS should be based on surgeons’ preferences.	Low	Strong (upgraded by experts)
G29	What is the role of the hand-assisted technique for pancreatic resections?	There is a limited role for hand-assisted procedures in contemporary minimally invasive pancreatic surgical practice.	Low	Strong (upgraded by experts)
Topic 14: Vessel and Hemorrhage control
G30	Is there any approach indicated when venous resections are considered during MIPD?	30.1 A careful expansion of selection criteria for MIPD to include major venous resections can be an option for highly experienced pancreatic surgeons in high-volume centers. Surgeons performing minimally invasive vascular resection should participate in a registry or have a prospectively maintained database to follow their outcomes.	Low	Weak
		30.2 Reserving the venous resection as the final step of a MIPD once dissection is completed and after correct exposure of the portal-mesenteric axis is recommended to minimize clamp time.	Low	Strong (upgraded by experts)
G31	Is there any approach indicated when arterial resections are considered during MIPS?	Arterial resection and/or reconstruction open or MI is not common practice. The MI approach for arterial resection/reconstruction or DP with celiac axis resection can be performed by highly experienced pancreatic surgeons in carefully selected pancreas tumors. Surgeons performing minimally invasive vascular resection should participate in a registry or have a prospectively maintained database to follow and report their outcomes	Low	Strong (upgraded by experts)

DP indicates distal pancreatectomy; MI, minimally invasive; MIPS, minimally invasive pancreatic surgery; MIDP, minimally invasive distal pancreatectomy; MIPD, minimally invasive pancreatoduodenectomy.