Distal pancreatectomy is indicated for lesions in the pancreatic body and tail. Understanding of the anatomical structure of the pancreas and its surroundings is required in various situations in left upper abdominal surgery including the laparoscopic approach. Spleen-preserving distal pancreatectomy is indicated for lesions confined to the pancreas. Two major spleen-preserving procedures reported are the Warshaw procedure that conserves the spleen by blood flow from the short gastric vessels and the Kimura procedure that preserves the spleen with splenic vessels. Considering the laparoscopic approach, the surgeon may preserve splenic vessels from the median toward the splenic hilum without mobilization of the spleen. A standard distal pancreatectomy using the medial approach is presented on video. The intraoperative complications of distal pancreatectomy can be minimized by avoiding splenic capsule injury, by careful differentiation of the splenic artery from the common hepatic artery, and by secure closure of the splenic vein stump. The incidence of postoperative pancreatic fistula following distal pancreatectomy is reported to be 13% in a nationwide pancreatic cancer registry. Based on the results of an international randomized trial of hand-sewn and staple closure of the pancreatic stump, the closure method of the pancreatic stump can be the surgeon's choice.
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