TABLE 6.

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

G32	What are the optimal techniques for the control of hemorrhage during MIPS?	32.1 Of paramount importance in minimizing excessive blood loss during MIPS is optimizing prevention strategies by assuring adequate exposure, gentle dissection, and securing critical vessels.	Low	Strong (upgraded by experts)
		32.2 Targeted interventions should be applied to treat intraoperative bleeding based on the extent and type of bleeding vessels. Bipolar cautery could be used to stop limited bleeding from small venous branches. Moderate venous bleeding can be temporally controlled by gauze compression and then by venous or arterial vessel clipping or suturing.	Low	Strong (upgraded by experts)
G33	What are the optimal techniques for control of hemorrhage during MIDP with spleen preservation?	33.1 Proximal preparation and slinging of the splenic artery and vein before proceeding with pancreatic dissection is suggested during a Kimura’s MI spleen preserving DP. This will allow their temporary clamping in case of hemorrhage or definitive section (Warshaw’s MIDP/splenectomy) if hemostasis is not achieved.	Low	Strong (upgraded by experts)
		33.2 Avoiding splenic injury is important during spleen-preserving pancreatic resections. Surgeons should be familiar with the best surgical practices to stop splenic bleeding.	Low	Strong (upgraded by experts)
Topic 15: Stump closure after Distal Pancreatectomy
G34	What are the technical details of pancreatic stump transection with staple devices indicated for the division of pancreatic parenchyma in MIDP?	34.1 In MIDP, a standardized technique for using a stapler to obtain adequate pancreatic stump compression is not available, although a gradual stepwise compression is advised.	Low	Strong (upgraded by experts)
		34.2 The optimal choice of cartridges tailored to pancreatic parenchymal features is currently lacking and should be further investigated.	Low	Weak
L35	Should staple versus another type of closure be used for the stump closure in LDP?	A stapling device can be considered for pancreatic stump closure in LDP. However, there are no clear advantages over other pancreatic stump closure techniques to prevent postoperative pancreatic fistula.	Moderate	Strong
R35	Should staple versus another type of closure be used for the stump closure in RDP?	A stapling device can be considered for pancreatic stump closure in RDP. However, there are no clear advantages over other pancreatic stump closure techniques to prevent postoperative pancreatic fistula.	Moderate	Strong
L36	Should staple line reinforcement versus no reinforcement be used for stump closure in LDP when a stapler is used?	Available evidence shows that the standard use of staple line reinforcements for pancreatic stump closure in LDP demonstrates no statistical, clinical benefits over no reinforcement stapling.	Moderate	Strong
R36	Should staple line reinforcement versus no reinforcement be used for stump closure in RDP when a stapler is used?	Available evidence shows that the standard use of staple line reinforcements for pancreatic stump closure in RDP demonstrates no statistical, clinical benefits over no reinforcement stapling	Moderate	Strong
Topic 16: Drain management
L37	Are there any specific recommendations on the use and positioning of drains in LDP other than those known in the traditional open approach?	There is limited evidence to support the routine use of drains in LDP. Further studies are required.	Low	Strong
R37	Are there any specific recommendations on the use and positioning of drains in RDP other than those known in the traditional open approach?	There is limited evidence to support the routine use of drains in RDP. Further studies are required.	Low	Strong
L38	Are there any specific recommendations on the use and positioning of drains in LPD other than those known in the traditional open approach?	Drain placement could be considered during LPD depending on patient, pancreas, and procedure risks, regardless of the approach. However, no evidence exists on the specific use of drains in LPD.	Moderate	Strong
R38	Are there any specific recommendations on the use and positioning of drains in RPD other than those known in the traditional open approach?	Drain placement could be considered during RPD depending on patient, pancreas, and procedure risks, regardless of the approach. However, no evidence exists on the specific use of drains in RPD.	Moderate	Strong

DP indicates distal pancreatectomy; LDP, laparoscopic distal pancreatectomy; LPD, laparoscopic pancreatoduodenectomy; MI, minimally invasive; MIDP, minimally invasive distal pancreatectomy; MIPS, minimally invasive pancreatic surgery; RDP, robot-assisted distal pancreatectomy; RPD, robot-assisted pancreatoduodenectomy.