ABSTRACT Introduction Minimally invasive distal pancreatectomy (MIDP), although demanding, offers clinical advantages. Male sex has been associated with increased operative difficulty; however, the anatomical basis for this disparity remains unclear. This study investigated sex‐related differences in MIDP outcomes using propensity score matching and evaluated physique‐related computed tomography (CT) indices potentially affecting MIDP complexity. Methods Among 187 patients who underwent distal pancreatectomy between 2010 and 2024, 77 who received MIDP were analyzed. Propensity score matching incorporated body mass index (BMI), pancreatic cancer, buried splenic artery, transection line, spleen preservation, and surgical approach. Surgical outcomes were compared between sexes before and after matching. Preoperative CT was used to measure anatomical distances and calculate physique‐related indices, including the umbilical‐pancreatic ratio: pancreas‐umbilicus distance divided by xiphoid‐umbilicus distance. Results After matching, 28 males and 28 females were included in the MIDP cohort. Males had longer operative times and a higher incidence of clinically relevant postoperative pancreatic fistula. CT analysis showed a greater pancreas‐to‐umbilicus distance and a higher umbilical‐pancreatic ratio in males. This ratio was correlated with BMI in males but not in females. Surgical difficulty, defined as operative time or intraoperative blood loss exceeding the 75th percentile, was independently associated with the umbilical‐pancreatic ratio, BMI, and pancreatic transection line on multivariable analysis. Conclusion The increased surgical difficulty observed in male patients undergoing MIDP may be explained by the positional relationship between the umbilicus and the pancreas, particularly in patients with high BMI, rather than by sex alone. Cephalad camera port positioning may therefore be beneficial, especially in high‐BMI male patients.
Fukada et al. (Thu,) studied this question.