Intraductal papillary mucinous neoplasm (IPMN) is defined as an intraductal mucin-producing neoplasm of the pancreatic ducts. IPMNs may be multifocal, have malignant potential and exhibit a broad histological spectrum ranging from adenoma to invasive carcinoma. The “hyperplasia-dysplasia-carcinoma sequence” in the evolution of IPMNs is considered very similar to the “adenoma-carcinoma sequence” of colorectal tumours. Patients with multifocal IPMN are potential candidates to total pancreatectomy, which still carries significant perioperative risks, especially in the elderly. In selected cases a reasonable alternative to total pancreatectomy is represented by the resection of the dominant tumour leaving deliberately in place the smaller, low-risk tumours. In this context, intraoperative ultrasonography (IOUS) can be useful to define the extent of IPMNs and to plan the surgical strategy. We report the case of a 84-year-old female with multiple IPMNs showing different stages of neoplastic progression up to invasive carcinoma. The patient underwent IOUS-guided distal splenopancreatectomy, while the small multiple branchduct type IPMNs of the head of the pancreas were considered at very low risk of neoplastic progression and were deliberately left in place. The patient is alive without recurrence 96 months after surgery and without evidence of progression of the branch-duct type IPMNs of the head of the pancreas. IOUS-guided pancreatectomy should be considered in selected elderly patients affected by multifocal IPMN evolved to invasive carcinoma without evidence of distant metastases.