Gene mutations in KRAS, CDKN2A, TP53, and SMAD4 contribute to abnormal epithelial proliferation within the pancreatic ducts [6]. This leads to the formation of pancreatic intraepithelial neoplasias which can progress to invasive pancreatic cancer when it spreads to other tissues and organs [6]. Diagnosis of pancreatic cancer requires multiple diagnostic scans, blood tests, and biopsies which are usually conducted when patients become symptomatic; by then there would be widespread metastasis and organ dysfunction [7]. In this case, our patient complained of abdominal pain radiating to the back. CT Scan and U/S with fine-needle aspiration can be used to confirm the diagnosis and surgical resection with adjuvant chemotherapy is the gold-standard treatment [6]. Only 10-20% of patients are eligible for surgical resection at the time of presentation [8].

Laparoscopy plays a big role in the diagnosis and management of pancreatic cancer. Small keyhole incisions are created and an instrument with a camera and tools known as the laparoscope is placed through the holes [9]. It allows the visualization of the entire abdominal cavity without the need to create large or midline incisions, allowing persons to recover at a quicker rate and have a short hospital stay [10]. There is less bleeding, pain, and a reduced risk of scarring after this procedure [9]. The risk of complications such as superficial site infections, perforation, and vascular injury ranges from 0.2 to 10.3% [11]. Laparoscopy can be used to take a biopsy, stage, and surgically resect the tumor when presented with a pancreatic mass.

For a pancreatic mass biopsy, samples of the tissue can be taken via percutaneous U/S-guided fine-needle aspiration, brush biopsy during an ERCP, and laparoscopic biopsy [12]. Laparoscopic biopsy is superior to the rest because it allows localization of the mass to allow accurate tissue sampling. In a retrospective review conducted on 76 people with pancreatic masses, there was a comparison of efficacy between CT-guided pancreatic biopsy and laparoscopic pancreatic biopsy [13]. It showed that laparoscopic biopsy had a higher diagnostic accuracy of 100% compared to the FNA with an accuracy of 81% [13].

Laparoscopic staging can occur after the diagnosis of pancreatic cancer has been established via biopsy. However, with advancements in CT imaging, the indications for laparoscopic staging of pancreatic masses have decreased [14]. Nevertheless, using laparoscopic U/S has been shown to detect locally advanced tumors with intraparenchymal involvement of surrounding structures and possible vascular involvement [14]. Some indications for laparoscopic U/S include large tumor size, involvement of the pancreatic neck, body, or tail, findings of hepatic involvement on CT that cannot be reached by percutaneous biopsy, and clinical findings pointing to advanced disease such as elevated CA19-9 of more than 150 U/ml, hypoalbuminemia and immense weight loss [11]. The sensitivity and specificity of diagnostic laparoscopy in identifying metastatic adenocarcinoma of the pancreas are 94% and 89% respectively [11]. In a study by Pisters et al, they found that in 4-13% of patients, laparoscopy detected metastatic cancer when there was no evidence found on CT [15]. This infers that laparoscopic staging reduces the number of radiologic investigations needed and the rate of subsequent non-therapeutic surgeries for non-resectable tumors.

Pancreaticoduodenectomy (PD) also known as the Whipple procedure can be conducted either open or laparoscopically. It involves the removal of the head of the pancreas, duodenum, gallbladder, and bile ducts in resectable pancreatic tumors [16]. A meta-analysis aimed to compare the benefits of a laparoscopic versus an open approach in 39771 patients [17]. They found that a laparoscopic approach was associated with less intraoperative blood loss, lower blood transfusion rate, less perioperative morbidity, lower wound infection rate, and shorter hospital stay length [16, 17]. However, the operative time was longer and patients who underwent this procedure had a smaller tumor size when compared to patients who underwent an open PD [17]. Absolute contraindications to laparoscopic procedures include perforation, peritonitis, history of surgical complications such as evisceration or shock, coagulopathy, and trauma with hemodynamic instability [11].

In this case, our patient underwent a needle-aspiration biopsy, however, an adequate diagnosis was not reached. The use of laparoscopic biopsy allowed a sufficient amount of tissue to be collected which provided the diagnosis of ductal pancreatic adenocarcinoma. According to the literature, biopsy, staging, and resection of pancreatic tumors via a laparoscopic approach are safe and effective and decrease unnecessary procedures that can impact the patient’s quality of life.