As with any patients with a newly discovered pancreatic mass, imaging and tissue diagnosis would be important to establish a diagnosis. Tumor markers, specifically CA19-9, should be obtained. It must be noted that 5–10% of patients can have a false negative due to do not produce CA19-9, as most common in patients Lewis-negative phenotpyes [3]. Additionally, patients with obstructive jaundice may exhibit an elevated CA19-9. In the patient presented, tissue diagnosis has confirmed the underlying pathology. Based on imaging criteria, this patient has borderline resectable disease, without overt evidence of metastatic disease. As mentioned in prior chapters, surgery currently continues to be the main means of providing a chance of cure. It must be noted that 5–15% of patients without radiographic evidence of metastatic disease have occult disease at the time of surgery. Exploratory laparotomy has its own risks and morbidity associated with the operation, in which staging or diagnostic laparoscopy may reduce the morbidity and costs associated with an aborted laparotomy.

Current National Comprehensive Cancer Network guidelines recommend staging laparoscopy as an adjunct to accurately stage patients with pancreatic adenocarcinoma, specifically patients with high-risk characteristics: borderline resectability, large primary tumors, bulky lymphadenopathy, highly elevated CA19-9, and/or extreme weight loss. Staging laparoscopy should be performed prior to exploration for surgical intent. Under general anesthesia, access to the abdomen can be obtained according to surgeon preference. Typically a periumbilical port for either a 5 or 10 mm 30° laparoscope would be placed first. This allows a good survey of the entire abdominal cavity. One or two additional 5 mm ports can be placed after surveying the abdomen for optimal port placement. Careful examination of the liver surface, falciform ligament, and peritoneal lining should be performed. Trocars should be placed to facilitate evaluation of the undersurface of the liver. Suspicious nodules should be biopsied and sent to pathology to evaluate for malignancy. Currently, there are no standardized steps; however, some surgeons have advocated for an extended procedure by accessing the lesser sac laparoscopically [4]. In the setting of neoadjuvant chemoradiation for borderline resectable and locally advanced adenocarcinoma, staging laparoscopy prior to initiating neoadjuvant therapy may allow to accurately stage patients with underlying metastatic disease.