Page 33 - Journal of Laparoscopic Surgery

WJOLS

Role of Minimal Access Surgery in Management of Infective Pancreatic Necrosis

is crucial to avoid inadvertent injury to surrounding vessels Percutaneous Necrosectomy
and viscera. Under computed tomography guidance, an 8 French pigtail
There should be very little resistance to dilatation and any nephrostomy catheter is inserted into the infected cavity, the
resistance encountered should lead to reevaluation to the line surgeon having carefully selected a path that will allow
of dilatation. The exception to this is during introduction of the subsequent dilatation. Correct route is to enter the area of
dilators through the skin, subcutaneous tissues and rib space infected necrosis between the lower pole of the spleen and the
and if this creates a problem increasing the size of the wound splenic flexure. In predominately right-sided pancreatic head
and dissecting down to the entry site may aid insertion. necrosis, a route through the gastrocolic omentum, anterior to
With the tract dilated, an Amplatz sheath is placed over the the duodenum is selected.
dilator and a rigid operating nephroscope can be introduced However, this results in a more technically difficult
into the cavity. The scope requires both an irrigation and biopsy necrosectomy and prevents dependent postoperative drainage.
channel. With continuous irrigation (warm sterile 0.9 % saline, The catheter is secured and the patient transferred to the
10–20 liters) under direct vision the necrosis can be removed operating room. With the patient under general anesthesia,
piecemeal. It is vitally important that granulating tissue, visible access to the abscess cavity is maintained using a guidewire,
vessels (aorta, superior mesenteric artery, splenic artery) or over which the catheter tract is then dilated to 30 French using
adherent tissue is not biopsied as it may result in catastrophic graduated dilators and radiologic guidance. This allows a
12
bleeding. 30 French Amplatz sheath to be inserted. An operating
Often at the first procedure, minimal necrosis can be nephroscope that allows intermittent irrigation and suction, with
removed and it is prudent to be conservative with this a 4 mm working channel, is then passed along the Amplatz
attempt. The procedure should be repeated on a weekly basis sheath into the abscess cavity. Piecemeal removal of solid
until the cavity appears clear and all visible necrosis is material is then performed using soft grasping forceps through
removed. At the end of each procedure, an irrigating system the working channel by repeatedly passing the instrument into
is constructed using a 28 French chest drain with extra side the cavity until all loose necrotic tissue is removed.
holes (cut to shape) sutured to a 10 French nasogastric tube. Finally, an 8 French umbilical catheter sutured to a 28 French
This is passed along the established tract until resistance is tube drain is then passed over a 12 French stiffener to the distal
met and then secured with a suture to the skin. Post- end of the cavity to allow continuous postoperative lavage
operatively, this can be irrigated with 0.9% saline via the (500 ml/hr) through the umbilical catheter. Because of the high-
nasogastric tube at a rate of 50 to 250 ml/hour depending on volume lavage, we use a fluid normally used for peritoneal lavage
the degree of contamination. to minimize the potential of electrolyte imbalance. The lavage is
continued at this rate until the lavage fluid clears or until a
PERCUTANEOUS NECROSECTOMY AND SINUS further procedure.
TRACT ENDOSCOPY IN THE MANAGEMENT OF
INFECTED PANCREATIC NECROSIS 15 SINUS TRACT ENDOSCOPY

Percutaneous Drainage In patients with a previous primary debridement, either at open
laparotomy or after the above technique, in whom residual
Percutaneous drains placed by the interventional radiologist in sepsis is suspected, a second computed tomogram is obtained
the treatment of infected necrosis should be used cautiously. and, provided there are no satellite collections, secondary
The catheter size will not cope with the solid necrotic tissue. sinus tract endoscopy is performed. In the operating room
It achieves drainage and not necrosectomy. There are two and under general anesthesia, the previously sited drain or
settings in which percutaneous drainage is useful. The first is drains are removed. Either a flexible or a rigid endoscopic
in an unstable septic patient with evidence of a tense rim- system is used, depending on the suspected amount of
enhanced collection (pancreatic abscess) with a significant fluid residual necrosis.
component on CT scanning. Sinus tract endoscopy using a flexible endoscope is
Percutaneous drainage in this setting may take the ‘heat tedious and only small fragments of necrotic tissue can be
out of the fire’, allow stabilization of the patient and ‘buy time’ removed with each pass of the endoscope. As a result, we
until necrosis is more amenable to surgical removal. The second have moved to using the operating nephroscope as described
setting in which percutaneous drainage is important is to above for most primary explorations. The major alteration in
establish the optimal route for dilatation and subsequent the technique is that the Amplatz sheath is not required.
percutaneous necrosectomy, should this be appropriate. This Access to pockets of necrosis is occasionally limited by the
will require careful discussion between the radiologist and rigidity of the system, and flexible endoscopy remains useful
surgeon. It usually involves a left-flank puncture and a route to check the tract before drain removal if residual necrosis is
along the axis of the body/tail of the pancreas. not suspected.

World Journal of Laparoscopic Surgery, September-December 2011;4(3):160-165 163