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Background and Aim Institutional standardization in the perioperative management of distal pancreatectomy (DP) has not been evaluated in a multicenter setting. The aim of the present study was to assess the influence of institutional standardization on the development of postoperative complications after DP. Methods Data were collected from 1515 patients who underwent DP in 2006, 2010, and 2014 at 53 institutions in Japan. A standardized institution (SI) was defined as one that implemented ≥6 of 11 quality initiatives according to departmental policy. There were 541 patients in the SI group and 974 in the non‐SI group. Clinical parameters were compared between groups. Risk factors for morbidity and mortality were assessed by logistic regression analysis with a mixed‐effects model. Results Proportion of patients who underwent DP in SI increased from 16.5% in 2006 to 46.4% in 2014. The SI group experienced an improved process of care and a lower frequency of severe complications vs the non‐SI group (grade III/IV Clavien‐Dindo; 22% vs 29%, respectively, clinically relevant postoperative pancreatic fistula; 22% vs 31%, respectively, P < .05 for both). Duration of in‐hospital stay in the SI group was significantly shorter than that in the non‐SI group (16 [5‐183] vs 20 postoperative days [5‐204], respectively; P = .002). Multivariate analysis with a mixed‐effects model showed that soft pancreas, late drain removal, excess blood loss and long surgical time were risk factors for post‐DP complications (P < .05). Pancreatic texture, drain management and surgical factors, but not standardization of care, were associated with a lower incidence of post‐DP complications.

Introduction Laparoscopic hemihepatectomy has not yet become widely accepted because of the technical difficulties in controlling each Glissonean pedicle laparoscopically. Materials and Surgical Technique The subjects in the present study included 12 patients who underwent laparoscopic left hemihepatectomy between August 2007 and June 2011. Arantius' ligament was divided. Retracting the caudal stump of the ligament revealed a space between the left Glissonean pedicle and the liver parenchyma. The left Glissonean pedicle could be easily encircled by using an Endo Retract Maxi. No Glissonean injuries, including bleeding or biliary leakage, occurred in any of the 12 patients. Discussion Therefore, the Arantius' ligament approach for the left extrahepatic Glissonean pedicle appears to be feasible and safe for successfully performing pure laparoscopic left hemihepatectomy.

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic liver resection, laparoscopic major liver resection remains a highly specialized field because there are major technical difficulties, such as hilar dissection and pedicle control. The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver. In contrast, the trunks of the secondary branches and more peripheral branches run inside the liver. The right, left, anterior, or posterior Glissonean pedicle can thus be tied and divided en bloc extrahepatically during open anatomical liver resection. Each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection using an Endo Retract Maxi or Endo Mini-Retract. This report describes a novel technique by which the extrahepatic Glissonean approach appears to be both feasible and safe for the performance of laparoscopic major liver resection.