**2. Laparoscopy-assisted distal pancreatectomy for benign lesions**

In benign cases, such as insulinoma, branch type intraductal papillary mucinous neoplasm, spleen-preserving pancreatectomy is performed. An 8-cm minilaparotomy incision is made in the middle upper abdomen. For obese patients, 10-cm laparotomy is better. An abdominal wall disc for hand assistance is placed at the site of the minilaparotomy. Ultrasonography probe can be inserted through this site for intrapancreatic imaging. A total of the two trocars are then placed. After abdominal access is established, the gastrocolic omentum is divided, and the splenic flexure is mobilized. The short gastric and left gastroepiploic vessels are not divided to prevent splenic volvulus after the operation. Retrosplenic Gerota's fascia is transected on the surface of the left kidney (Figure 1a). Then, the posterior plane of Gerota's fascia is dissected from lateral to medial direction, allowing the distal pancreas and spleen detached from retroperitoneum.

Fig. 1. Procedures in laparoscopy assisted distal pancreatectomya) Retrosplenic Gerota's fascia is transected on the surface of the left kidney.Then, the posterior plane of Gerota's fascia is dissected from lateral to medial direction, allowing the distal pancreas and spleen detached from retroperitoneum. b)The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy for hand assistance at the epigastrium.

The distal pancreas, spleen, and left side of stomack are then pulled out of the peritoneal cavity through the minilaparotomy for hand assistance at the epigastrium (Figure 1b).

The three ways of laparoscopy-assisted distal pancreatectomy: 1) for benign lesions, 2) for low-grade malignant lesions, and 3) for invasive pancreatic ductal cancers, are presented in this chapter. Laparoscopic procedure is used for the retroperitoneal dissection under the left

In benign cases, such as insulinoma, branch type intraductal papillary mucinous neoplasm, spleen-preserving pancreatectomy is performed. An 8-cm minilaparotomy incision is made in the middle upper abdomen. For obese patients, 10-cm laparotomy is better. An abdominal wall disc for hand assistance is placed at the site of the minilaparotomy. Ultrasonography probe can be inserted through this site for intrapancreatic imaging. A total of the two trocars are then placed. After abdominal access is established, the gastrocolic omentum is divided, and the splenic flexure is mobilized. The short gastric and left gastroepiploic vessels are not divided to prevent splenic volvulus after the operation. Retrosplenic Gerota's fascia is transected on the surface of the left kidney (Figure 1a). Then, the posterior plane of Gerota's fascia is dissected from lateral to medial direction, allowing

a b

The distal pancreas, spleen, and left side of stomack are then pulled out of the peritoneal cavity through the minilaparotomy for hand assistance at the epigastrium (Figure 1b).

Fig. 1. Procedures in laparoscopy assisted distal pancreatectomya) Retrosplenic Gerota's fascia is transected on the surface of the left kidney.Then, the posterior plane of Gerota's fascia is dissected from lateral to medial direction, allowing the distal pancreas and spleen detached from retroperitoneum. b)The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy for hand assistance at the epigastrium.

**2. Laparoscopy-assisted distal pancreatectomy for benign lesions** 

hand assistance in all types of lesions including cancers.

the distal pancreas and spleen detached from retroperitoneum.

Spleen and gastrosplenic ligament preserving pancreatectomy is performed under direct vision (Figure 2). The advantage of extracorporeal procedure is the safety and certainty in dissection of the splenic vessels and preparation of the pancreatic stump. The transected main pancreatic duct is doubly ligated, and the transected pancreatic stump is sewn manually. The preserved spleen, stomach and splenic vessels are placed back in the peritoneal cavity after resection.

Fig. 2. Dissection of the distal pancreas. The distal pancreas (black arrow) is dissected from the surrounding tissues (spleen, splenic artery, splenic vein, stomach) under direct vision extracorporeally. White arrow: spleen, black arrow head: splenic vessels.

Distal pancreatectomy with preservation of the spleen was first reported in 1988 (Warshow, 1988). The advantage of preserving the spleen is obvious; it reduces the risk of postoperative severe inflammation and peripheral blood count aberration. Preserving the spleen has been a major procedure in distal pancreatectomy. Warshow reported a case of splenic abscess that occurred after sacrificing the splenic artery and vein (Warshow, 1988). Kimura et al. reported five patients successfully treated with splenic vessel-preserving distal pancreatectomy to maintain the blood supply to the spleen and to avoid splenic necrosis and abscess (Kimura et al., 1996; Kimura et al., 2010). Spleen-preserving pancreatectomy has recently been shown to have comparable risk of complication to standard pancreatectomy where the spleen is removed. Nevertheless, spleen-preserving pancreatectomy remains an uncommon and technically demanding operation, due to the difficulty in dissecting the

Laparoscopy-Assisted Distal Pancreatectomy 57

complications. Hand-sewn parenchymal closure and duct ligation are an advantage of this extracorporeal pancreatic resection, to prevent pancreatic juice leakage, compared with the procedure done by laparoscopy only. We could safely and securely handle the pancreatic

Fig. 3. Dissected distal pancreas and spleen. The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium. Pancreatic resection

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

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

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.

and closure of the residual pancreatic stump is performed under direct vision.

promising (Hirota et al., 2005; Hirota et al., 2010).

**cancers** 

duct and fine branches of the splenic vessels under the direct vision.

distal pancreas from the splenic vessels. Another advantage of our procedure is the safety in dissecting the distal pancreas from the splenic vessels. The displacement of the spleen with the inherent risk of torsion or hemorrhage is another disadvantage of spleen-preserving pancreatectomy. If spleen-preserving pancreatectomy is performed, the spleen is often free in the abdomen, where it is prone to torsion or trauma. Various techniques have been described to reposition the spleen (splenopexy). Appu et al. report a novel technique for splenic repositioning and fixation, using peritoneal pocket (Appu et al., 2005). We experienced one case of splenic bleeding due to venous congestion after spleen-preserving pancreatic tail resection using Appu's splenopexy. After that experience we are preserving the gastrosplenic ligament.

This approach is suitable for the very distal lesion of the pancreas. However, if the posterior plane of Gerota's fascia is dissected, this method could be applied to more proximal lesion. For obese patients, because the pulling out through the small laparotomy is difficult, 10 cm incision is preferable. This procedure is applicable only for lesions in the pancreatic body and tail. For the benign head lesions, another approach should be conducted (Hirota et al., 2007).

Preservation of gastrosplenic ligament and extracorporeal preparation of transected pancreatic stump and splenic vessels under direct vision are useful measures for troubles in spleen-preserving distal pancreatectomy under minimal incision approach assisted by laparotomy.
