Artery-rst approaches to pancreatic resections have been widely practiced in the setting of a pancrearticoduodenectomy or Whipple procedure for pancreatic cancer. The purposes of artery-rst approaches are to determine the resectability in the early phase of operation, to perform more oncologic resection by isolation of the tumor from the blood ow and to reduce the intraoperative blood loss. Until recently, however, artery approaches to a distal pancreatectomy (DP) have been scarcely performed due to the difculty in approaching the origin of the splenic artery before the transection of the pancreas especially in open surgery. In contrast, by laparoscopic approaches, a surgeon can enter the retroperitoneal space behind the pancreatic body taking advantage of the caudo-cranial angle view through a laparoscope and explore the origin of the celiac artery from the aorta and the origin of the splenic artery without dividing the pancreas. The same approaches can be carried out in open sur­gery also with techniques, so-called “Tiger Den” approach, as follows. First, we divide the ligament of Treitz and mobilize the fourth portion of the duodenum and proximal jejunum. The adi­pose tissue in the retroperitoneal space is dissected and the infe­rior vena cava (IVC) is exposed. The mesentery of the transverse colon is also divided along the posterior border of the pancreatic body, the dissection over the IVC is extended to the left and the left renal vein is exposed. By careful dissections over the aorta, a surgeon can identify the origin of superior mesenteric artery (SMA) and that of the celiac artery. Large Kelly forceps can be passed through the retroperitoneal space behind the pancreatic body toward the left side of the left gastric artery. A Penrose drain is passed thorough the retroperitoneal space and the pan­creatic body is lifted upward by the Penrose drain as this proce-

may be required.