Dissection Around the Superior Border of the Pancreas Using a Gastrohepatic Ligament Approach During Minimally Invasive Distal Pancreatectomy (with Video).

introductionThe gastrohepatic ligament approach is a form of minimally invasive distal pancreatectomy (MIDP) with spleen preservation

methodsThe patient was a 79-year-old male with pancreatic tail acinar cell carcinoma. The surgical technique was as follows. First, the gastrohepatic ligament was divided extensively, and all subsequent dissections around the superior border of the pancreas were performed through the open gastrohepatic ligament. After the common hepatic and splenic arteries were isolated, the splenic artery was ligated or divided. Toldt's fusion fascia was then dissected toward the upper pole of the spleen, and Gerota's fascia was identified. The gastropancreatic fold was dissected from the proximal to the distal side. Depending on the tumor status, Gerota's fascia was dissected toward the upper pole of the spleen at the cranial side of the pancreas, and the left adrenal gland was exposed. This approach aims to reduce blood loss by ligating the splenic artery first and to identify the anatomical landmarks early by dissecting posteriorly along the left side of the celiac artery. Conversion to the conventional approach will be considered if the procedure proceeds with difficulties.

resultsThe operation time and intraoperative blood loss were 238 min and 10 mL, respectively.

conclusionAlthough this approach is based on our experience, the gastrohepatic ligament approach could be an option for performing MIDP.