Precise intraoperative localization of small, deep, or non-palpable pancreatic lesions remains challenging in minimally invasive pancreatic surgery. Laparoscopic ultrasound (LUS), although standard, may have limited accuracy due to restricted maneuverability, intervening air, or fibrosis, especially for lesions <10 mm or located in complex anatomical regions. These limitations can hinder real-time surgical navigation, compromise margin assessment, and risk unnecessary pancreatic parenchymal resection. A reliable, high-resolution intraoperative imaging adjunct capable of providing immediate feedback and seamless integration into the surgical workflow is needed.

We developed a structured, preplanned integration of intraoperative endoscopic ultrasound (EUS) as an innovative adjunct during pancreatic tumor resection. This approach consists of: (1) incorporation of EUS as a predetermined intraoperative step; (2) same-operator continuity, with the endoscopist responsible for preoperative staging also performing the intraoperative examination; (3) sterile deployment of a linear-array echoendoscope without altering patient positioning or compromising the surgical field; and (4) continuous, real-time communication between endoscopist and surgeon to guide lesion localization, define resection planes, and verify post-resection status.

Four adult patients with technically challenging pancreatic lesions ranging from 5–10 mm, including neuroendocrine tumors and a branch-duct IPMN with a mural nodule, underwent pancreatic surgery with planned intraoperative EUS. Feasibility was demonstrated in all cases: EUS was performed successfully under sterile conditions, without contamination events, technical failures, or interference with surgical workflow. In each case, intraoperative EUS provided improved real-time lesion localization compared with LUS, particularly for small or non-palpable lesions. It enabled precise delineation of resection margins, supported parenchyma-sparing strategies, and improved intraoperative orientation. Immediate post-resection EUS confirmed absence of residual disease and excluded vascular or biliary complications before closure. No EUS-related adverse events occurred, and all patients had favorable postoperative courses, with no imaging- or procedure-related complications. The operating room environment accommodated the endoscopy team without changes to patient positioning or surgical ergonomics. The four cases are summarized in Table 1.

Intraoperative EUS was feasible, safe, and compatible with pancreatic surgery in this early experience. It may offer potential advantages in lesion localization, margin assessment, and real-time decision-making, particularly for small or difficult-to-localize lesions. These findings warrant further study to clarify its clinical impact and comparative performance as an intraoperative imaging adjunct.