Background: The adaptation of laparoscopic surgical techniques to pancreatic diseases has been slow since the procedures are technically complex and the oncologic implications are unclear. Only small series of laparoscopic distal pancreatectomy (LDP) have been reported, and the advantages of laparoscopic over open distal pancreatectomy (ODP) have yet to be confirmed.Methods: MEDLINE and PubMed were systematically searched from the last 10 years for series reporting at least 10 LDP or 100 ODP cases. We also reviewed our own experience with LDP and ODP and analyzed these data. The effects of operative approach were assessed by calculating pooled estimates of blood loss, operative time, complications, mortality, pathologic parameters, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio (OR).Results: Twenty-two case series were included (n=1,075 patients). There were more females in the LDP group (42.6% vs. 62.9%; p<0.0001), and operative blood loss was greater for ODP (699±15 mL vs. 269±20 mL, p=0.0002). The spleen was preserved in 19.8% of ODP and 38.8% of LDP (p<0.0001). The laparoscopic approach increased the odds of having a postoperative complication (OR 1.32, 95% CI: 1.02-1.70, p=0.03). The rate for pancreatic fistula was similar for LDP (17.9%) and ODP (14.3%) (OR 1.31, 95% CI: 0.94-1.83, p=0.11). Postoperative pseudocyst (OR 99.85, 95% CI: 6.05-1647.13, p=0.01) and splenic infarct (OR 5.12, 95% CI: 1.38-19.00, p=0.02) were higher in the LPD group. Other complications were more frequent in the ODP group (p=0.02). For example, patients having an ODP were more likely to require re-operation (OR 2.23, 95% CI: 1.01-4.93, p=0.05). The rate of an R1 resection was similar (OPD 1.3%, LDP 1.5%, p=0.80). Lymph node harvest was not consistently reported in the outside series, but among our own patients undergoing LDP, there were fewer nodes (5.3±1.5) examined than in patients who had ODP (9.3±0.7, p=0.01). There was a trend towards increased length of stay for ODP (11.0±1.6 days) compared with LDP (7.5±1.1 days; p=0.15). Mortality rate (ODP 4.1%, LDP 5.0%, p=0.72) was similar regardless of operative approach.Conclusions: While LDP offers some advantages over ODP, the complication rate appears higher and there may be fewer lymph nodes sampled. Additional studies will be required to reliably asses the pros and cons of laparoscopic pancreatic surgery, and to clarify the technique and indications for specific clinical conditions.