**4. Laparoscopy-assisted distal pancreatectomy for invasive pancreatic ductal cancers**

Laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic cancer. The aim of no-touch distal pancreatectomy is to decrease the shedding of cancer cells, and to achieve negative transection margins. All drainage vessels from the pancreatic body and tail have been ligated and divided during the early phase of the operation. Squeezing and handling the tumor prior to ligation of the surrounding vessels during pancreatectomy may increase the risk of shedding cancer cells into the portal vein, retroperitoneum and/or peritoneal cavity. Although the no-touch isolation technique has not been shown to increase cancer survival or decrease recurrence, it is theoretically promising (Hirota et al., 2005; Hirota et al., 2010).

Another aim is to resect cancers by wrapping them within Gerota's fascia. Perirenal tissue beyond Gerota's fascia is often protected from the autodigestion in severe acute pancreatitis.

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Because cancer cell invasion is dependent on protease activity, Gerota's fascia may function as a barrier against protease-mediated invasion of cancer cells.

Division of the pancreas, splenic artery, and splenic vein is done under direct vision through minilaparotomy at epigastrium. Following the division of the gastrocolic ligament, the posterior surface of the pancreatic neck is tunneled by blunt dissection. The pancreas is transected after ligating the left side of the pancreas. The splenic artery and vein are ligated and divided at the origin and at the confluence with the superior mesenteric vein, respectively. As mentioned by Fagniez and Munoz-Bongrand, early division of the pancreatic neck provides superior access to control the splenic vessels (Fagniez & Munoz-Bongrand, 1999). Then, division of the left gastroepiploic and short gastric vessels is done under laparoscope with left hand assistance. At this point, all drainage vessels from the pancreatic body and tail have been ligated and divided. Lastly, retroperitoneal dissection behind the Gerota's fascia is performed lateral to medial direction laparoscopically.
