**1. Introduction**

52 Updated Topics in Minimally Invasive Abdominal Surgery

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The advantage of laparoscopic surgery is obvious and has been extended to pancreatic and splenic operations. Since 1994, various laparoscopic pancreatectomy, including pancreatoduodenectomy (Gagner & Pomp, 1994), enucleation (Gagner et al., 1996; Dexter et al., 1999), and distal pancreatectomy (Gagner et al. 1996; Sussman et al., 1996), have been performed. As for laparoscopic splenectomy, nowadays it can be conducted safely even for splenomegaly due to portal hypertension (Hama et al., 2008). Open pancreatic surgery requires a relatively large incision for a small lesion, and therefore the potential benefits of the laparoscopic approach are substantial. The most common indications for laparoscopic pancreatic resection were presumed benign pancreatic diseases, such as insulinoma or localized neuroendocrine neoplasms and branch type intraductal papillary mucinous neoplasms. The most common indication for laparoscopic pancreatic resection appears to be enucleations and distal pancreatectomy. Laparoscopic pancreatectomy, however, is still technically rather difficult because of the retroperitoneal position of the pancreas and the complex anatomical relationship between the pancreas and surrounding vessels. Thus, hand-assisted laparoscopic pancreatectomy is gaining recognition as a new and feasible technique that introduces a surgeon's hand into the abdominal cavity during laparoscopic surgery (Klingler et al., 1998; Shinchi et al., 2001; Kaneko et al., 2004). As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally (Hirota et al., 2009). Furthermore, laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic cancer. For invasive pancreatic ductal cancers, the transection of the pancreas, splenic artery and vein, left gastroepiploic vessels, and short gastric vessels is performed at first to prevent the dissemination of cancer cells. Division of the pancreas, splenic artery, and splenic vein is done under direct vision through minilaparotomy at epigastrium. Division of the left gastroepiploic and short gastric vessels is done under laparoscope with left hand assistance. And then, retroperitoneal dissection is performed laparoscopically. In this way, the same no-touch distal pancreatectomy as open operation can be achieved.

<sup>\*</sup> Daisuke Hashimoto, Kazuya Sakata, Hideyuki Kuroki, Youhei Tanaka, Takatoshi Ishiko,

Yu Motomura, Shinji Ishikawa, Yoshitaka Kiyota, Tetsumasa Arita, Atsushi Inayoshi and Yasushi Yagi *Department of Surgery, Kumamoto Regional Medical Center, Kumamoto-city, Japan* 

Laparoscopy-Assisted Distal Pancreatectomy 55

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

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

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

extracorporeally. White arrow: spleen, black arrow head: splenic vessels.

peritoneal cavity after resection.

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 hand assistance in all types of lesions including cancers.
