The evolution of spleen-preserving distal pancreatectomy:Warshaw’s procedure and the Kimura technique—toward physiological preservation

Spleen-preserving distal pancreatectomy (SPDP) is an established surgical approach for selected benign and low-grade malignant lesions of the pancreatic body and tail. Two principal techniques are used: the Warshaw procedure, which divides the splenic vessels while relying on collateral perfusion, and the Kimura technique, which preserves the splenic artery and vein. A narrative review of the historical development and current evidence regarding SPDP was conducted with particular focus on the conceptual differences between the Warshaw procedure and the Kimura technique. The Warshaw procedure represented a pivotal advance by demonstrating that splenic preservation was technically feasible during distal pancreatectomy. However, this technique alters splenic hemodynamics by relying on collateral circulation through the short gastric vessels, which may lead to complications such as splenic infarction or perigastric varices. The Kimura technique preserves both the splenic artery and vein and therefore aims to maintain physiological splenic perfusion and venous drainage. Comparative studies generally report fewer radiologic splenic ischemic and perigastric venous complications with vessel preservation, although postoperative splenic vein stenosis or occlusion may occur and direct evidence of superior long-term immunological or patient-reported outcomes remains limited. The Kimura technique represents an important conceptual step from anatomical organ preservation toward preservation of normal splenic hemodynamics; this physiological rationale should be distinguished from patient-important clinical outcomes that remain incompletely established. The development of SPDP reflects the broader evolution of pancreatic surgery toward organ and functional preservation. The Kimura technique refined this concept by attempting to maintain normal splenic circulation. In the modern minimally invasive era, vessel-preserving SPDP is increasingly achievable. We advocate a “Kimura-first” strategy in which splenic vessel preservation is the preferred initial approach when it can be performed safely and when durable vascular patency can reasonably be expected, while the Warshaw procedure remains an important alternative when vessel preservation is unsafe or technically unfavorable.