As early as the beginning of this century, laparoscopy was used clinically for the diagnosis of abdominal diseases until the 1960s, when it was widely used in the diagnosis of liver diseases, the nature of ascites, and metastatic tumors of the peritoneum, and in 1972 Meyer Burg applied laparoscopy to the diagnosis of pancreatic diseases [1]. The role of laparoscopy in the diagnosis of pancreatic diseases was limited due to limited diagnostic tools. Since the world’s first laparoscopic cholecystectomy in 1987, laparoscopy has taken a revolutionary step from diagnosis to treatment, with an increasingly wide range of clinical applications. With the continuous development of laparoscopic surgical techniques and instruments, especially the application of laparoscopic ultrasound, laparoscopy is gradually applied to the diagnosis and treatment of pancreatic diseases. Laparoscopic diagnosis of pancreatic diseases I. Preoperative preparation: the same as the preparation for caesarean section. Preoperative fasting for 12 hours, skin preparation, preoperative routine chest radiographs and EKG, clean enema, placement of gastric tube, sedation and atropine, while strictly grasp the contraindications to laparoscopy. II. Instruments: In addition to all routine instruments, the following instruments are particularly important (a) 30° or 45° view laparoscope. (B) Laparoscopic ultrasound probe (7.5MHZ, linear array): used to diagnose pancreatic surface and interstitial tumors and intrahepatic metastasis, vascular infiltration, lymphatic metastasis, etc.. (C) Biopsy forceps and puncture needle: biopsy the primary foci or suspected metastases under direct vision or ultrasound guidance to clarify the pathology. (B) Position: mostly supine position is used, and the operating table is rotated to see the whole picture of liver and spleen. If the patient has ascites, ascites is aspirated and filled with an equal amount of gas. Fourth, anesthesia: general anesthesia is mostly used. At present, there are foreign reports of laparoscopic exploration with NO instead of CO2 pneumoperitoneum under local anesthesia, and most of the diagnostic laparoscopic exploration has been carried out under sedation and local anesthesia in Moscow and Tbilisi Oncological Centers, general anesthesia is mostly used for pediatric diagnostic laparoscopy and most of the laparoscopic surgeries [2]. Compared with general anesthesia, local anesthesia has the following benefits: avoiding complications that may arise from general anesthesia, maintaining contact with the patient during the operation, less traumatic, and favoring early recovery of the patient. V. Basic operation steps: subumbilical Veress needle puncture, gas injection 3-4L, pressure 2Kpa (15mmhg) or so. In the umbilicus and the left and right midclavicular line and rib margin intersection were poke holes into the 10mm trocars and various operating instruments, in the gastrocolic ligament electrocautery a small hole, placed in 30 ° or 45 ° laparoscopic lens, into the small omental cavity, can see the pancreas. Some people also put the lens through the small omental hole, can clearly see the pancreatic body and pancreatic tail, the head of the pancreas is not easy to see, can be detected with a probe bar, when found suspicious lesions can be palpated with a probe bar, under the direct vision of the fine needle puncture, suction cytology, our country Zhang Jinkun et al. with this method of examination of 12 cases, there are 10 cases of success, of which the pancreatic head of cancer in 1 case, the pancreatic body of 1 case of carcinoma, chronic pancreatitis in 4 cases, a case of confined cysts, the normal pancreas in 3 cases [3]. After visualization of the lesion, it can be palpated with a finger through a 1-2 cm mini-incision in the pancreatic cavity to assess the size, texture, and activity of the lesion. Subsequently, adjacent organs such as colon, duodenum, liver, spleen, stomach, portal vein, upper and lower mesenteric vascular roots, abdominal cavity and distant pelvis are explored in turn for metastasis, and intraoperative ultrasound is often supplemented to clarify the diagnosis, and the whole process of the examination can be videotaped to record. After laparoscopy, patients should be hospitalized for 48 hours for observation. In the first 4 hours, every 1/2 hour inspection, incision observation 2-3 days, 5 days after the removal of sutures. If liver or pancreatic tissue biopsy is performed, the patient should be observed for bleeding or biliary or pancreatic leakage. Laparoscopic exploration has the following advantages over open exploration: good visualization, ability to obtain the same or even more information, less pain, less expense, smaller scars, and less surgical risk. The disadvantages are: laparoscopy is a two-dimensional imaging, and it can only see the surface of the organs and cannot palpate the deep structures. Therefore, although it can reduce the frequency and danger of cesarean section, it cannot completely replace cesarean section. Compared with CT, US, MRI, etc., laparoscopy has good visualization through a high-quality light source system, camera video and TV system, which can directly see lesions smaller than 1 mm on the surface of the liver pancreas and abdominal cavity, such small lesions cannot be determined by any imaging examination. According to some prospective studies, the sensitivity of techniques such as US, CT, and MRI for the diagnosis of intra-abdominal metastatic tumors is only 79%-80%, and the disadvantage of these examinations is that they have false positives.The false positive rate of US and CT examinations is in the range of 20%, whereas the rate of nuclear scans is more than 30%. US and CT examinations are unsatisfactory in 10-25% of cases due to interference from intestinal gas. Metastatic lesions of parenchymal organs that are less than 1 cm may be missed by either US, CT or nuclear scanning. For small tumors, especially those on the peritoneal surface, the diagnostic sensitivity is extremely low. Laparoscopy, on the other hand, can be 96% effective in identifying intraperitoneal metastases and is complementary to imaging methods such as CT and US. Even a 1-mm peritoneal implantation nodule can be visualized by laparoscopy, and tissue biopsy can be performed, making the diagnostic positivity and specificity 100%. However, US is more sensitive than laparoscopy for determining the full extent of hepatic metastases, so the diagnostic accuracy can be improved if the two methods are combined [4]. Often liver metastases are suggested by US and CT and can be further identified by laparoscopy. It can be seen that laparoscopy, as a diagnostic technique, has its own unique advantages and disadvantages, and cannot completely replace other techniques, but is more suitable to become a supplement to other techniques. At the same time in the process of laparoscopy, the integration of other diagnostic techniques can greatly improve the correctness of the diagnosis of pancreatic diseases. (I) Combined application with laparoscopic ultrasound technology Laparoscopic ultrasound (LUS), compared with traditional ultrasound (US) and endoscopic ultrasound (EUS), can not only detect tumors <1cm in the target under direct vision, but also deeply investigate the relationship between the tumor and adjacent lymph nodes, blood vessels, and surrounding organs under direct vision. It is also an important tool for the evaluation of intrahepatic metastatic tumors.Champault G reported that in the evaluation of pancreatic cancer patients with US, EUS, CT and LUS, LUS can detect about 15%-30% of tiny metastatic foci that cannot be detected by other diagnostics, which can change the treatment plan for this group of patients [5]. Thus, LUS has its own unique advantages over other ultrasound techniques: a clear detection target and a wide range of motion. And it makes up for the lack of tactile sense of laparoscopy, which cannot detect interstitial pancreatic lesions, liver metastases and vascular infiltration, while laparoscopy also makes up for the defects of ultrasound, i.e., it can accurately detect metastatic foci on the surface of the liver, and the distant peritoneum, and even as deep as 1-2 mm in the pelvis under direct visualization. (ii) Abdominal lavage Under laparoscopic exploration, 0.9% NS 100ml is injected into the subhepatic space, the patient's abdomen is shaken, and the operating table is tilted so that the liquid is in full contact with the surrounding tissues, and the liquid is aspirated under direct vision, and the samples are centrifuged for cytological examination. The reason why patients with pancreatic cancer have a poor prognosis and a long-term survival rate of <1% is related to the fact that pancreatic tumors have cancer cells shedding into the abdominal cavity for planting at an early stage. Positive cytological examination: it suggests that intraperitoneal chemotherapy should be carried out at an early stage, which provides a reference for whether surgical treatment is possible, and also implies that patients have poor prognosis and low long-term survival rate. (iii) Puncture Under the direct vision of laparoscopy, accurate biopsy can be performed on the primary pancreatic lesion and the surrounding suspected metastatic foci. However, it is worth mentioning that we do not advocate biopsy on the primary foci where no metastatic foci are found but suspected to be pancreatic cancer. It has been shown in many studies that biopsy of cancerous tissues increases the chance of cancer cell detachment, abdominal implantation, and metastasis at the open site, thus depriving the chance of surgery for this part of the patients who could have been treated surgically. If the cancer is biopsied by mistake during operation, abdominal radiotherapy can be added after operation to reduce the chance of metastasis. For those who have a clear diagnosis of primary cancer and suspicious metastatic foci are found in the surrounding tissues, biopsy can be performed to clarify the pathology, which will provide a reliable basis for the possibility of operation. At present, most pancreatic diseases can be clearly diagnosed by general routine methods. Laparoscopy is mainly used for preoperative staging assessment of pancreatic cancer, i.e., it is divided into 2 stages: those that can be surgically resected and those that cannot be surgically resected. In order to clarify the tumor stage, during intraoperative exploration, we generally take the following indicators as indications that the cancer cannot be resected: 1. lesions ≥5 cm 2. metastases in the liver, peritoneum, etc. 3. infiltration of the cancer into the surrounding tissues (duodenum, stomach, common bile duct, posterior peritoneum, mesenteric arteries) 4. infiltration and encapsulation of large blood vessels (e.g., portal vein, hepatic artery, vena cava). For these patients who cannot undergo cancer resection can be treated laparoscopically with internal diversion or palliative care, which will be further described in future pages. It is well known that pancreatic cancer is one of the diseases with the worst prognosis among all malignant tumors; at the time of diagnosis, 45% of the cancers have distant metastases, 40% of the cancers have spread locally and are inoperable, and only 15% of the cancers are resectable [6]. In the past, CT, ultrasound and angiography could be evaluated, but their correct rate was quite limited, and the highest diagnostic rate of thin-scan and enhanced CT reported by Fuhrman M et al. was only 88% [7], which made it difficult to detect small tumors on the surface of the liver and the peritoneum, while laparoscopy not only detected metastatic foci of 1-2 mm on the surface of the liver and the peritoneum, but also detected deep pelvic metastases that could not be detected by even conventional caesarean section [8]. Laparoscopy can not only find 1-2mm metastatic foci on the surface of liver and peritoneum, but also even find metastatic foci deep to the pelvis, which can not be detected by conventional dissection. According to statistics, 27% of pancreatic head cancer and 65% of pancreatic body and pancreatic tail cancer have metastasis on the surface of peritoneum and liver. Therefore, correct staging of pancreatic cancer by laparoscopy can change the original treatment plan, avoid unnecessary caesarean section, reduce the occurrence of surgical risk and postoperative complications, and the rapid proliferation of tumor cells due to the suppression of the immune system by trauma, which is very important for some patients, especially those who cannot undergo pancreaticoduodenectomy and those who do not need pancreatic surgery. For some patients, especially those who cannot undergo pancreaticoduodenectomy and those who do not need to undergo bypass surgery, it can reduce pain and improve the quality of life. At present, laparoscopy and LUS are generally combined to stage pancreatic cancer, and a large number of literatures have reported that this is the best way to clarify whether pancreatic cancer can be operated radically.Among the 90 patients reported by Emery: the tumors were first staged by laparoscopy, and 36 cases could be surgically resected, 41 cases could not be surgically resected, and 13 cases were difficult to determine. Of these 41 unresectable cancers, 10 had liver metastases, 15 had vascular infiltration, 9 had peritoneal extrahepatic metastases, and 7 had peritoneal or hilar lymph node metastases. Subsequently, the patients were re-explored with LUS, which confirmed the correct diagnosis of 36 resectable, and 4 unresectable tumors by laparoscopy, respectively. For the 13 cases of difficult-to-stage cancer, 8 cases were found to be unresectable, including 3 cases of extensive portal vein metastasis, 3 cases of extensive metastasis to the superior mesenteric vessels, 1 case of distal abdominal and peritoneal metastasis, and 1 case of metastasis to the hepatic artery, and only 5 cases could be surgically resected. Through dissection, it was also clear that 4 of the 5 cases were resectable, and 1 case had infiltration of the abdominal arterial plexus [8]. It can be seen that the combined application of LUS greatly improves the rate of laparoscopic confirmation of tumor staging, especially for infiltration of blood vessels and intrahepatic metastases with considerable help. This study showed that the combined application of the two can lead to a diagnostic sensitivity of 100%, specificity of 98%, and correctness of 95%, which is a considerable improvement compared with the original CT maximum diagnostic rate of 88%. Finally, we would like to say that laparoscopy, as a diagnostic technique, has its advantages, i.e., good broad visualization; it also has its disadvantages, i.e., lack of tactile sensation. Although the combination with other techniques can make up for the mutual deficiencies, it will also bring some new problems, such as: post-puncture abdominal implantation and the transfer of the opening site. Therefore, there are also objections to the use of laparoscopy for routine preoperative evaluation of patients with pancreatic cancer. Nowadays, we still suggest that CT and ultrasound should be the first line of diagnostic method, supplemented by laparoscopy and other techniques; however, it is worth mentioning that laparoscopy, supplemented by other techniques, can not match CT and ultrasound in terms of correct assessment of whether pancreatic cancer can be resected or not. In today's rapidly changing technology, the rise of a new technology always has its pros and cons. Laparoscopy applied to the diagnosis of diseases, especially pancreatic disease diagnosis, is still in its infancy in our country, and there are many problems on the road of its development that are worth exploring and researching together. Laparoscopic treatment of pancreatic diseases Since the first successful use of laparoscopic technology for the removal of the first case of gallbladder by Mouret in France in 1987, laparoscopy has been rapidly popularized into various operations in general surgery. In the past 10 years, all kinds of surgeries, especially laparoscopic cholecystectomy, have been greatly developed in China, while pancreatic surgery has not been carried out much due to the technical difficulties. At present, laparoscopic pancreatic surgery is mainly the following: pancreatectomy, islet cell tumor resection, gallbladder gastrojejunostomy, pseudocyst internal drainage, necrotizing pancreatitis, removal of necrotic tissue plus abdominal drainage. Brief introduction is as follows: I. Instruments: the following are some of the main operating instruments 45 ° viewing angle laparoscope, laparoscopic ultrasound scissors (optional), non-invasive grasping forceps, toothed grasping forceps, needle-holding forceps, right curved forceps, right curved scissors, electrocoagulation straight hemostatic forceps, applying clamps, in vivo and ex vivo tying device, ligation propeller, Endo-GIA (30 mm), laparoscopic ultrasound device (optional), endocystic pouch. Specific instruments may vary with individual habits. Most of the current camera equipment is adequate for the procedure, but a 3-CCD camera would provide better visualization. A laparoscope with a 45° viewing angle is recommended, but surgery can also be performed with a 30° viewing angle, and a 0° viewing angle lens, which is more parallel to the pancreas, does not meet the surgical needs as well. Laparoscopic ultrasound equipment, although expensive, can identify small tumors in the pancreatic body and provide good localization for surgery. In addition, the application of ultrasonic knife can be precise cutting of tissue with and good coagulation, reduce the burns and adhesion to the tissue, less smoke and less scorched scabs, so that the operation to maintain a clear vision. Second, the selection of patients: the main target of surgery is benign cystic degeneration of pancreatic tail and distal pancreatic body. Preoperative assessment of the benignity and malignancy of the tumor is crucial. Generally, CT and ultrasound can make a correct diagnosis, and usually no preoperative angiography is performed. Occasionally, malignant tumors are suspected intraoperatively and should be immediately transferred to open abdomen. To date, there is no literature supporting laparoscopic surgery in patients with pancreatic cancer. In addition pancreatic endocrine tumors, or APUD tumors, most of which are islet cell tumors, 80% of which are benign and 60-70% of which are solitary, are not difficult to diagnose but are relatively difficult to localize. With angiography, only 35-75% of these tumors can be localized. If angiography fails, blood samples can be taken from the splenic vein, portal vein, superior mesenteric vein and other blood vessels, and the hormone concentration in each segment of the vein can be measured to clearly localize the tumor. Preoperative CT, ultrasound is less useful for localization, generally can only show more than 1cm tumor, if intraoperative laparoscopic ultrasound can be used to explore them, it will be very easy to find these small tumors. Even if the vascular imaging is clear, ultrasound should be used to localize again, after all, it is important for guiding the treatment. Operator training: The operator should have experience in traditional open pancreatic surgery, have a thorough understanding of the anatomy of the pancreas, and years of history of laparoscopic surgery, be able to perform laparoscopic cholecystectomy skillfully, and be able to use both hands to operate the instruments simultaneously to meet the need for intraoperative suturing and tying knots, and be familiar with the use of laparoscopy with a 30 ° or 45 ° angle of view. For the first operation, if possible, it is best to ask a surgeon who has experience in laparoscopic pancreatic surgery to provide on-site guidance. The patient is placed in a modified lithotomy position as shown in Figure 1. The surgeon is located between the legs, the mirror holder and monitor are located on the right side of the operating table, and the first assistant and hand-washing nurse are located on the left side of the operating table. The operating table was placed in the 20° Trenlenburg position. A sandbag was placed on the back of the patient's left shoulder to elevate the left chest about 20°. V. Surgical operation: (A) Laparoscopic pancreatectomy, mainly divided into three kinds: 1, pancreatic body tail resection, splenectomy, 2, retention of the spleen of the pancreatic body tail resection, 3, pancreatic head duodenectomy. 1, pancreatic body tail resection, splenectomy: conventional subumbilical Veress needle puncture to form a pneumoperitoneum, placement of trocars (10mm) and 45 ° angle laparoscopy. The remaining four trocars (10 mm) were inserted under direct vision. Under two-handed operation, the abdominal cavity was completely explored before separating the tissues. The adjacency of the spleen, stomach, and colon was also evaluated. The gastrocolic ligament was opened to enter the lesser omental cavity, and bleeding, if any, was stopped by electrocautery or titanium clips. If intraoperative adhesions of the stomach or colon are detected suggesting a possible malignant lesion, the laparotomy should be intermediate. If there is no infiltration of adhesions in the surrounding tissues, the operation can be continued. The peritoneum at the lower edge of the pancreas is opened with electrocoagulation scissors to expose the pancreas. The splenic artery is located at the superior border of the pancreas, and a tortuous splenic artery is encountered and may not be found until the peritoneum is completely separated. The splenic artery is dissected with a double-channel clamp using an applicator, and blunt dissection of the peritoneum from the pancreas and tumor is continued to the spleen, where the splenogastric ligament and splenodiaphragmatic ligament are dissected with an electrocoagulation hook, respectively. The pancreas was gently lifted with either blunt instrument and Endo-GIA (30 mm) was inserted. The pancreas is clamped along the edge of the tumor and at the point where the splenic artery was previously dissected. Depending on the size of the pancreas, the pancreas may be clamped several times to dissect the pancreas while removing peripancreatic tissues around the pancreas that have a poor blood supply. After dissecting the pancreas, the splenogastric ligament can be isolated, and its vessels can be dissected by knotting, clamping, Endo-GIA, ultrasonic knife, etc., depending on the situation, and continuously isolated to the diaphragm, including the short gastric artery. The residual splenogastric ligament can be separated by electrocoagulation or clamping, and the spleen and distal pancreas can be completely freed. A solid internal pouch is placed, and a water-soluble lubricant is applied to the outside of the pouch to assist in the removal of the specimen. The specimen is gently placed into the internal pouch, mashed up, and then the band is tightened, and the specimen is removed from the left epigastric region. Finally, the abdominal cavity is lavaged with saline, and a drain is placed into the stump of the pancreas, and the aperture site is closed. Distal pancreatectomy with spleen preservation: The steps of entering the lesser omentum are the same as before, while the process of separating the pancreas is slightly different. Preserving the spleen is mainly suitable for endocrine tumors and benign cystadenomas. For islet cell tumors, preoperative localization is critical. If preoperative localization is difficult, laparoscopic ultrasound can be used intraoperatively to find these small tumors. If the tumor is easy to see and conditions allow, the pancreas can be preserved to remove the tumor. After the positioning is clear, it can be operated with both hands, stripping the tumor with electrocoagulation scissors, making mattress suture with fine silk thread along the incision side and then interrupted suture, and finally placing an abdominal drainage tube in the pancreatic bed. 3, Pancreaticoduodenectomy: Three cases of laparoscopic pancreaticoduodenectomy with pylorus preservation (one case each of chronic pancreatitis, juxtapetal tumors, and pancreatic cancer) have been reported by a working group [9]. Reconstruction of the digestive tract follows open surgery, including anastomosis of the biliary tract, pancreas and duodenum. Although, it is technically feasible, it does not reflect the superiority of laparoscopic surgery and the hospitalization time is rather prolonged due to pancreatic leakage and delayed gastric emptying. This aspect of surgery is still in the experimental phase and reports of long-term follow-up are lacking. (ii) Islet cell tumor resection: the specific operation is the same as the distal pancreatectomy with spleen preservation, which will not be repeated here. (C) biliary and gastrojejunal anastomosis: mainly used for patients with pancreatic cancer that cannot be resected for palliative surgery, such patients should choose the least traumatic, the least complications, and the most meaningful surgery for the patient. Under general anesthesia in the supine position, a subumbilical puncture is made to form a pneumoperitoneum, and trocars are placed separately as in Figure 1. The gallbladder was punctured, about 50 ml of bile was withdrawn and injected into the contrast medium, and after cholangiography confirmed that the choledochal duct was open, a suitable bilioenteric and gastrojejunal anastomosis was selected, and after incision, 30 mm Endo-GIA and 60 mm Endo-GIA (or 30 mm′2) were placed to be sutured, and the residual end was sutured with a 3/0 suture. M Rhodes et al. used this method successfully in 10 patients. The average postoperative survival was 201 days, which was higher than the average survival of 150 days in previous open procedures [10]. (iv) Internal drainage of pseudocysts: Internal drainage should be preferred for pseudocysts. There have been many foreign reports of laparoscopic gastrostomy for cysts. The operation procedure is similar to that of laparotomy: after the formation of the pneumoperitoneum, a trocar needle (12mm) with a gas bag is placed in the cardia or corresponding part of the fundus of the stomach into the gastric cavity, and after the gas bag is flushed, the trocar needle is withdrawn, so that the stomach wall is tightly attached to the abdominal wall and the gastric cavity is fully exposed. At the same time, air was injected through the gastric tube, and the laparoscopic head was placed in the gastric cavity, which revealed a prominent mass in the posterior wall of the stomach. The optimal drainage site was explored with laparoscopic ultrasound, the cyst was punctured, and the opening was enlarged with an electrocoagulation hook and closed with Endo-GIA. Finally, the cyst was withdrawn and the gastric wall incision was closed again with Endo-GIA. (v) Drainage of acute necrotizing pancreatitis with necrotic tissue removal: Three trocars (10 mm) are usually used to perform the procedure, and after forming a pneumoperitoneum, the gastrocolic ligament is opened, and the pancreas is seen to be congested with hematochezia and edema, subperitoneal hemorrhage, or foci of greyish-black necrosis. After extracting the exudate for cell culture, the peritoneum of the lower border of the pancreas and the lateral peritoneum of the descending duodenum were incised, and all necrotic tissue and fibrin pseudomembranes that could be peeled off were removed with grasping forceps. Repeatedly irrigate the abdominal cavity and extrapancreatic space until clean, and then dispose of 2-3 single-lumen or double-lumen tubes for drainage in the corresponding pancreatic bed, as shown in Fig. 6. This method has a good field of vision, less bleeding and pancreatic damage, and fewer postoperative complications compared with open laparotomy, but it is technically difficult, especially for the person who needs to carry out the "triple fistula", and if the drainage tube is not placed properly, it can cause the spread of infection in the abdominal cavity. If the drainage tube is not placed properly, it can cause the spread of infection in the abdominal cavity. Therefore, it is necessary to strictly grasp the indications for surgery and operate with caution. In summary, laparoscopic technology is being utilized in the diagnosis and treatment of various pancreatic diseases. Because of its complex operation and high technical requirements, it is not carried out much in our country, while it has been developed in foreign countries due to its early development. We have reason to believe that with the continuous development of various laparoscopic surgeries in China and the accumulation and improvement of surgeons' technical experience, our laparoscopic experts will be able to create a broader and better future in the laparoscopic diagnosis and treatment of pancreatic diseases with their own wisdom and hands.