Laparoscopy-Assisted Distal Pancreatectomy

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.