Laparoscopic Radical Antegrade Modular Pancreatosplenectomy: Safety, Feasibility and Early Outcome

Abstract

Background: Radical Antegrade Modular Pancreatosplenectomy (RAMPS) was developed to improve oncological clearance during distal pancreatectomy by providing systematic lymphadenectomy and facilitating appropriate posterior retroperitoneal margin dissection. With advances in minimally invasive surgery, laparoscopic RAMPS (Lap-RAMPS) has emerged as a technically demanding approach that combines the principles of RAMPS with the potential perioperative advantages of laparoscopy. This study evaluated the feasibility, safety, perioperative characteristics, and short-term outcomes of laparoscopic RAMPS in patients with malignant tumours of the pancreatic body and tail. Methods: A prospective observational study was conducted in the Department of Minimal Access and General Surgery, Government Medical College, Srinagar, over an 18 month period from August 2024 to February 2026. Thirty consecutive adult patients with resectable malignant tumours of the pancreatic body and tail underwent planned RAMPS. Demographic characteristics, clinical presentation, operative approach, conversion, intraoperative complications, postoperative morbidity, pancreatic fistula, pathological findings, and short-term functional outcomes were assessed. All procedures were performed using the anterior RAMPS approach. Postoperative clinical assessment was performed at 1 and 3 weeks after discharge. Results: The study included 30 patients with a mean age of 57.0±7.2 years (range, 34-67 years). Eighteen patients (60%) were male and 12 (40%) were female, giving a male-to-female ratio of 1.5:1. Abdominal pain was the commonest presenting symptom (73.3%), followed by weight loss (53.3%) and anorexia (40.0%). Laparoscopic RAMPS was successfully completed in 27 patients (90%), while three patients (10%) required conversion to open surgery because of intraoperative technical difficulty and bleeding, including splenic artery-related vascular injury. Four intraoperative complications occurred (13.3%). No intraoperative blood transfusion or intraoperative mortality was recorded. Histopathological examination revealed pancreatic adenocarcinoma in 25 patients, pancreatic neuroendocrine tumour in four, and squamous cell carcinoma in one. R0 resection was achieved in all 30 patients. Postoperatively, six patients (20%) developed complications. Two patients developed postoperative pancreatic fistula, classified as Grade B according to the International Study Group of Pancreatic Surgery criteria, and were managed conservatively. Delayed gastric emptying occurred in six patients. Splenic vein thrombosis occurred in one patient. Endocrine and/or exocrine pancreatic insufficiency was documented in eight patients, while new-onset diabetes mellitus was identified in 16 patients during follow-up assessment. There was no major postoperative morbidity, reoperation, or 30-day mortality. Conclusion: Laparoscopic RAMPS was technically feasible in 90% of patients in this single-centre prospective series and was associated with acceptable short-term morbidity and no perioperative mortality. The findings support the feasibility of laparoscopic RAMPS in appropriately selected patients when performed by an experienced surgical team. Larger multicentre studies with longer oncological follow-up are required to determine its long-term survival and recurrence outcomes.