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Introduction: For many patients with pancreatic cancer, CT is inadequate in determining unresectability; 10-48% of patients deemed resectable receive an unnecessary laparotomy. Accordingly, many groups have studied the role for diagnostic laparoscopy (DL) though none have evaluated it in an MRI driven practice. Methods: All MRI’s administered for suspected pancreatic cancer between December 2004 and 2008 were evaluated. Radiographic diagnoses were prospective judged resectability based on the presence of metastases and relationship of the tumor with the surrounding vasculature. Unresectable disease received endoscopic biliary and duodenal stenting. Resectable and borderline disease received Whipples and double bypasses if unresectable intraoperatively. We performed a decision analysis for the cost-effectiveness of incorporating DL. We queried our billing database to render average costs for all inpatients with pancreatic cancer who received Whipples, double-bypasses and double-stenting procedures. We did not include professional fees. The marginal cost of DL was derived from the itemized costs of the materials, space and ancillary staff, presuming routine utilization, no missed metastases, and no complications. Results: Preoperative MRI deemed 94 patients’ tumors resectable; 86 agreed to a laparotomy. Six patients were found to have metastases intraoperatively and 15 patients had unresectable disease (vascular involvement or benign pancreatitis) and thus received double-bypass procedures for which the average total cost of the hospitalization was $21,957.18. Whipples were provided to 65 patients at an average cost of $26,122.43. DL would thus be offered to 86 patients. For the 6 patients with metastases, it would be the only operation ($3604.07). This would be added to the cost of endoscopic stenting procedures, which results in an average total cost of hospitalization of $18,451.41. For the patients without metastases, the marginal cost of DL before a laparotomy would be $2651.71, which we added to the total costs above. Conclusions: For DL to be cost-effective, it would have to increase the rate at which we diverted patients to the GI lab for palliative stenting. In our model, DL would increase our costs by $191,072.18, equivalent to the total cost of hospitalization for treating 7 patients with Whipple procedures. Given our rate of missed metastases - 6% - and presuming perfect yield from DL, 15 patients would have unnecessary DL for every patient with occult metastases. For DL to be cost-effective, its intraoperative yield would have to be 70%.