Our first case was a female patient who underwent surgery with the diagnosis of renal cancer. During her follow-up period, she referred us with multifocal pancreatic metastasis of a renal cancer. After this first case, we continued to perform single-access laparoscopic pancreas resection for different pathologies including insulinoma, adenocarcinoma, mucinous cyst adenoma, and nonfunctional neuroendocrine tumor.

After performing ten cases of SALS distal pancreatectomies, we achieved to preserve spleen only in one of the cases. This patient had an insulinoma located at pancreatic tail. In this case, after defining the localization of the lesion with laparoscopic ultrasonography, we preserved short gastric vessels. Although we sacrificed the splenic artery, we protected the spleen successfully in the end. In three cases (30 %), we had low-flow pancreatic fistula which ceased spontaneously during the follow-up period. In one case, we had umbilical trocar site hernia. We had no conversion to multi-trocar laparoscopy or open surgery, and no mortality occurred. The main problem was the duration of the surgical procedure which was as expected longer than standard laparoscopic distal pancreatectomies.

In all our cases, we routinely used suction drains which were located in the pancreatectomy bed. Before the removal of drains, we always analyzed the drain fluid for amylase level. If this level was three times higher than normal serum amylase levels, we did not remove the drain and accepted as pancreatic fistula.

One of the main challenging steps of the procedure was caused by the sword fight of the laparoscopic instruments both inside and outside of the abdomen. In order to prevent or minimize this challenge, the use of roticulated instruments is mandatory for this technique. Today, we have even angulated energy devices that are very useful for hemostasis in advanced laparoscopic procedures. The smoke inside the abdomen and air leak are the other minor technical problems during advanced single-access laparoscopic procedures. Using standard laparoscopic trocars can be a solution for the easy evacuation of intra-abdominal fog. Air leak is usually caused by deformation of the special single-access trocars toward the end of the procedure due to overextension of the laparoscopic tools. You can deal with this problem by having an extra single-access trocar for change where needed. The details of our SALS distal pancreatectomy experience are summarized in Table 11.2.