**3. Laparoscopy-assisted distal pancreatectomy for low grade malignant lesions**

In low-grade malignant cases, such as mutinous cystic neoplasm, solid pseudopapillary neoplasm, medium-sized neuroendocrine neoplasm, the procedure is almost the same as in benign cases except the resection of the spleen and splenic vessels for lymph node dissection. The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium (Figure 3). Pancreatic resection and closure of the residual pancreatic stump is performed safely under direct vision extracorporeally.

The successful management of the pancreatic stump remains the challenge of this procedure. In some laparoscopic enucleation series, the rate for low volume pancreatic fistula is reported to be high (Mabrut et al., 2005). This complication does not create an important problem as long as the main duct is not injured. Even though self-limiting, the pancreatic fistula formation rate remains high after either laparoscopic enucleation or resection. Pancreatic fistula after distal pancreatectomy has been a topic of decades, even in the era of laparoscopic pancreatectomy. Patterson et al. collected data from the literature on morbidity after open and laparoscopic pancreatic resections, and found that the rate of pancreatic fistula ranged from 20% to 33% after laparoscopic pancreatectomy and from 5% to 23% after open pancreatectomy (Patterson et al., 2001). The way in which the surgeon approaches the pancreatic transection seems to be important. Ninety-seven percent of the patients underwent laparoscopic transection of the pancreas by use of a stapling technique (Mabrut et al., 2005). Closing the pancreatic stump with interrupted mattress sutures and selectively ligating the pancreatic duct, the usual practice in open surgery, are more difficult to replicate laparoscopically. This factor could explain the high rate of pancreas-related

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

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.,

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

In low-grade malignant cases, such as mutinous cystic neoplasm, solid pseudopapillary neoplasm, medium-sized neuroendocrine neoplasm, the procedure is almost the same as in benign cases except the resection of the spleen and splenic vessels for lymph node dissection. The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium (Figure 3). Pancreatic resection and closure of the

The successful management of the pancreatic stump remains the challenge of this procedure. In some laparoscopic enucleation series, the rate for low volume pancreatic fistula is reported to be high (Mabrut et al., 2005). This complication does not create an important problem as long as the main duct is not injured. Even though self-limiting, the pancreatic fistula formation rate remains high after either laparoscopic enucleation or resection. Pancreatic fistula after distal pancreatectomy has been a topic of decades, even in the era of laparoscopic pancreatectomy. Patterson et al. collected data from the literature on morbidity after open and laparoscopic pancreatic resections, and found that the rate of pancreatic fistula ranged from 20% to 33% after laparoscopic pancreatectomy and from 5% to 23% after open pancreatectomy (Patterson et al., 2001). The way in which the surgeon approaches the pancreatic transection seems to be important. Ninety-seven percent of the patients underwent laparoscopic transection of the pancreas by use of a stapling technique (Mabrut et al., 2005). Closing the pancreatic stump with interrupted mattress sutures and selectively ligating the pancreatic duct, the usual practice in open surgery, are more difficult to replicate laparoscopically. This factor could explain the high rate of pancreas-related

**3. Laparoscopy-assisted distal pancreatectomy for low grade malignant** 

residual pancreatic stump is performed safely under direct vision extracorporeally.

the gastrosplenic ligament.

2007).

laparotomy.

**lesions** 

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

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