Page 32 - Journal of Laparoscopic Surgery

Kiran Somani, Dnyanesh M Belekar

– Laparoscopic transmesocolic necrosectomy colonic flexures, providing better exposure and reducing the
– Laparoscopic transgastrocolic necrosectomy risk of subsequent injury to the colon from tube drains.
– Endoscopic transgastric necrosectomy The head of the pancreas then can be approached anteriorly
– Endoscopic transduodenal necrosectomy and posteriorly (after Kocherization). If the abdomen is opened
– Percutaneous necrosectomy and sinus tract endoscopy 15 though a bilateral subcostal incision, inline with the opening to
– Translumbar retroperitoneal endoscopic necrosectomy 13 the lesser sac, subsequent laparotomies do not need to disturb
• Radio-guided surgical approaches: the greater peritoneal sac or the upper abdomen.
– MRI-assisted necrosectomy 6 It is not necessarily a one-stage procedure, especially if an
– Video-assisted retroperitoneoscopic debridement 17 early necrosectomy is embarked on. Necrosectomy is a careful
– Nephroscopic retroperitoneal 16 process, best accomplished by an educated finger. The extent
– Endoscopic transgastric necrosectomy of the cavity can be explored and the gentle separation of necrotic
– Endoscopic transduodenal necrosectomy material accomplished. Necrotic extensions from the primary
– Endoscopic transpapillary necrosectomy cavity need to be explored, often into the root of the small
– Endoscopic transmural necrosectomy bowel mesentery and down the retrocolic gutters.
– Combined method Care must be taken to remove only what easily separates
– EUS-guided drainage. and to avoid injury to major vessels. The removal of necrotic
material may be assisted by irrigation, pulsatile irrigation, gauze
TIMING OF SURGERY and sponge forceps. When contained by a mature wall, it is
advisable to avoid opening up the area too widely. The next
There has been a change in the treatment standard for
necrotizing pancreatitis from an aggressive policy favoring early step is placement of large-bore, soft, dependent drains to cover
surgical intervention to a more conservative strategy of delayed all the regions of what is often a complex area.
Continuous lavage with peritoneal dialysis fluid, at flow
7
and less invasive intervention. Early surgery was advocated rates of 300 to 1000 ml/h, may reduce the need to reoperate and
in order to remove the focus of infection and terminate the
inflammatory process. often is continued for 2 to 3 weeks. The most common
postoperative complications are hemorrhage and fistulization
However, the inflammatory cascades are not easily switched (pancreas, small and large intestine). The use of packing is
off and are compounded by the surgery itself. Early surgery is lifesaving for major hemorrhage that occurs at the time of
more difficult because necrotic tissue is immature and not easily necrosectomy, but when used routinely, it is associated with a
separated from viable tissue, resulting in a significant risk of higher incidence of enteric fistulas. 3
bleeding. Additionally, early surgery may infect sterile necrosis.
Delayed surgery may allow time for stabilization of the patient NEPHROSCOPIC RETROPERITONEAL PANCREATIC
and the more easy removal of well-demarcated necrosum. NECROSECTOMY 16
There is a balance between operating too early and leaving Under CECT guidance, access to the necrotic cavity is obtained
it too late and the decision needs to be individualized. The via the predetermined approach. Under local anesthetic (in the
decision is aided by close surveillance of the patients’ clinical absence of mechanical ventilation), an Accustick set is used to
trajectory with frequent clinical review and daily CRP access the area of necrosis. This is subsequently exchanged
measurements. (with the use of a guidewire) for a percutaneous drainage
From a review of published studies, the lowest mortality is catheter. The patient is transferred to the operating suite.
associated with surgery after 3 to 4 weeks. However, the clinical Depending on the patient’s condition, the following
picture (severity and evolution) should be the primary procedure can be performed under either general anesthetic or
determinant of the timing of intervention.
local anesthetic infiltration with IV sedation (anesthetist
controlled). The patient is placed supine and a sandbag can be
BASIC PRINCIPLES OF PANCREATIC used under the site of catheter entry to improve access to the
NECROSECTOMY BY OPEN TECHNIQUE
tract with the operating nephroscope. The entry site is prepared
Pancreatic resection is a historical approach that has been in a sterile fashion using a waterproof drape with a catch all as
associated with unacceptable complication and mortality rates. used for urological procedures as large amounts of irrigation
Pancreatic necrosectomy involves removing the devitalized are required. Under fluoroscopic control, the previously placed
pancreatic and peripancreatic tissue and drainage of associated percutaneous catheter is exchanged for a guidewire.
pus. The usual approach to the pancreas is through the Using a Seldinger technique the tract can then be dilated to
gastrocolic omentum into the lesser sac. 30 French using a renal dilatation set. It is important to reinforce
Sometimes, it is easy to enter the region through the the guidewire with the supplied plastic tapered sheath to prevent
transverse mesocolon from the greater sac and to the left of the buckling and misplacement of the wire. A three-dimensional
DJ flexure. At the same time, it is useful to take down both concept of the surrounding structures as shown by the CE-CT

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