While minimally invasive approaches gain favor for appropriately selected patients, open distal pancreatectomy remains a commonly performed operation for diseases of the distal pancreas, particularly in cases with adhesions due to significant past surgical history or pancreatitis, or in cases with locally invasive malignancy. Understanding of this operation is therefore fundamental for the pancreas surgeon. Splenectomy is typically performed with distal pancreatectomy given the intimate relationship between the pancreatic body and splenic artery and vein, as well as the need for thorough lymphadenectomy and en bloc resection when operating for malignancy. Preoperative planning must include contrast enhanced cross-sectional imaging to understand both the arterial and portal venous anatomy to plan resection, as well as to plan for the site of transection of the pancreas. Distal pancreatectomy may generally be performed in an antegrade (medial-to-lateral) approach or the more classic retrograde (lateral-to-medial) approach. Radical antegrade modular pancreatosplenectomy (RAMPS) is a frequently referenced technique for antegrade approach. Advantages to this method include minimization of blood loss by early vascular control, as well as improved lymphadenectomy and negative tangential margins in cases of oncologic resection. During a RAMPS procedure, the retroperitoneal dissection plane may be “modulated” to include the anterior renal fascia (anterior RAMPS) or to include the adrenal gland en bloc (posterior RAMPS). In contrast, retrograde distal pancreatectomy is performed by first mobilizing the spleen to gain upward traction on the pancreas as it is dissected from the retroperitoneum in a lateral-to-medial manner. The surgeon must be comfortable with both approaches to adapt as needed to the case at hand. This chapter describes both methods as well as technical pearls and pitfalls including strategies for sealing the pancreatic transection line.