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4 Acute Pancreatitis: Surgical Therapies
of critical structures along the path of the catheter from the skin puncture site to
the necrosis cavity. At a minimum, CT scan with intravenous contrast is needed
to provide detailed information of the necrosis cavity and its relationship to sur-
rounding structures.
67
Fig. 4.7 (a) Summary of the step-up approach (PANTER trial) for management of infected acute
pancreatic necrosis. (b) Axial abdominal schematic showing a large, retroperitoneal peripancreatic
walled-off cavity lled with necrotic debris. A percutaneous drain is placed in this retroperitoneal
cavity. (c) Pneumoretroperitoneum-assisted VARD (PRA-VARD) procedure: (A) An incision is
made around the percutaneous drain leading into the necrotic peripancreatic cavity. (B) A gel port
is placed into this incision with two 5mm trocars and one 12mm trocar. (C) The cavity is insufated and a laparoscope, a grasper, and a suction irrigator are used to clear the necrotic debris
68
Fig. 4.7 (continued)
O. Alser et al.
• If feasible, anticoagulation should be held prior to the procedure to allow for suf-
cient time for anticoagulation effects to resolve. If urgent intervention is needed,
reversal of anticoagulation may be utilized depending on the anticoagulation in
question. Patient’s platelet count and international normalized ratio should be
checked prior to the procedure.
Catheter Drainage Procedure Steps
• Following imaging review, a choice of the route of approach to the cavity is
made. Almost all pancreatic necrosis collections can be accessed via a retroperi-
toneal or transperitoneal approach (Fig.4.7b). The retroperitoneal approach is
preferred and recommended (usually the left retroperitoneal route) due to lower
risk of complications (by avoiding the intra-abdominal organs) and its ease of
subsequently being able to be converted into a video-assisted retroperitoneal
necrosectomy (VARD) procedure if needed. The retroperitoneal route also avoids
intraperitoneal contamination with infection from the infected necrosis cavity.
• Patient is sedated under monitored anesthesia in conjunction with local anesthe-
sia. If needed, general endotracheal intubation anesthesia may be utilized.
• Patient is positioned based on the route of access to the cavity, and this may be
supine for transperitoneal approach or right lateral decubitus position for the left
retroperitoneal approach. A limited ultrasound or CT imaging may be performed
to ensure the route chosen is still appropriate after patient positioning since the
anatomy may be altered by positional shifts of intra-abdominal organs.
• Choice of catheter size: A minimum catheter size of at least 12 French is recom-
mended based on the PANTER trial. Catheter can be upsized up to a 24 French
catheter if needed.
4 Acute Pancreatitis: Surgical Therapies
69
• Under imaging guidance, the cavity is accessed by a large bore needle puncture
and a guidewire passed into it.
• Using the Seldinger technique, over the guidewire subcutaneous dilation is per-
formed to create a wide tract from the skin puncture site to the cavity. Serial
dilation is performed until the diameter of the chosen catheter is reached.
• The chosen catheter is then passed over the guidewire, through the dilated tract
and into the infected necrosis cavity and correct positioning in the cavity is con-
rmed by drainage of the infected pus and imaging conrmation.
• An attempt should always be made to drain most of the infected uid during the
procedure by aspiration.
• Drainage catheter is then secured in place with 2–0 Nylon or Prolene suture.
• Post-procedure, the catheter should be ushed regularly 3–4 times daily to avoid
clogging.
• Drainage catheter upsizing and/or placement of additional drains may be neces-
sary for adequate drainage of infected necrosis.
• Drain evaluation via contrast injection (drain sinogram) or CECT are used as
needed to optimize the location and function of the drain.
Percutaneous Catheter Drainage Pitfalls
• Formation of pancreatico-cutaneous or pancreatico-entero-cutaneous stula in
approximately 20% of cases. Pancreatico-cutaneous stula forms when there is
main ductal communication with the infected necrosis cavity. As a result of this
internal “pancreatico-cavity” stula, there is drainage of pancreatic ductal uid
into the cavity. Percutaneous catheter placement converts this internal stula into
a pancreatico-cutaneous stula. This also applies to cases of internal stula
between the alimentary tract and the necrosis cavity. These pancreatico- cutaneous
or pancreatico-entero-cutaneous stulae can usually be managed nonoperatively
with prolonged drainage.
• Catheter dislodgement.
• Bowel perforation.
• Vascular injury with acute bleeding.
• Pneumothorax.
• Introduction of infection into the pleural cavity if the catheter traverses the lower
pleural cavity. This may lead to infected pleural effusion/abscess.
Video-Assisted Retroperitoneal Drainage (VARD) Procedure
As mentioned above, catheter drainage is usually successful in 35–50% of cases of
infected pancreatic necrosis and no additional necrosectomy is needed. If percutaneous catheter drainage is not successful in resolving sepsis or if symptoms arising
from infected necrosis persist, a VARD procedure will be the next option in the
step-up approach to management.
70
O. Alser et al.
Pre-procedure and Preparation Pearls for VARD Procedure
• VARD procedure should always be preceded by percutaneous catheter drainage,
per the PANTER trial protocol. In preparation for VARD procedure, these
patients should be evaluated to ensure the percutaneous catheter drainage has
failed, despite catheter optimization, prior to proceeding with VARD procedure.
• Most VARD procedures will be done after preceding left retroperitoneal catheter
drainage. However, some patients may have bilateral retroperitoneal catheters if
they have bilateral retroperitoneal extensions of the infected necrosis cavity. In
these cases of bilateral catheters, a pre-VARD procedure evaluation should be
done to determine if the patient can tolerate bilateral VARD procedures under the
same general anesthetic or if the VARD procedure should be staged by doing a
unilateral VARD rst, followed by a later subsequent contralateral VARD proce-
dure once the patient has recovered.
• A thorough review of updated imaging should be done to ensure the necrosis
cavity has developed a mature wall around it to facilitate a safe necrosectomy.
• Standard VARD procedure is done using an open incision around the drainage
catheter entry site into the cavity and then a laparoscope is passed through this
into the cavity for visualization and graspers are used to perform necrosectomy.
• Below we will also describe our technique of pneumo-retroperitoneum-assisted
VARD procedure (PRA-VARD).
Standard VARD Procedure Steps
• The VARD procedure is done under general anesthesia.
• For unilateral VARD procedure, usually the left side, the patient is positioned in
a right lateral decubitus position.
• A ank incision is made on either side of the drain exit site.
• The drain is used as a guide to extend the incision deeper all the way into the
necrosis cavity, with entry into the cavity conrmed by immediate release of
purulent, often foul-smelling uid. The uid portion of the cavity contents is
suctioned out.
• Any visible loose infected necrosis tissue is sequentially removed using grasping
forceps until cleared.
• A 0° videoscope is then introduced into the necrosis cavity and used to guide
further necrosectomy under direct visualization.
• Laparoscopic grasping instruments are used alongside the scope, to sequentially
remove any loose and loosely adherent necrosis tissues from the cavity.
• Any rmly adherent tissue should be left in place to avoid debridement of viable
tissue and avoid signicant bleeding.
• Once debridement of loose necrosis tissue is completed, a cavity lavage with
saline is performed and existing percutaneous drainage catheters are removed.
• At least two large bore (usually 19 French) surgical drains are placed into the
cavity. Postoperative lavage may be performed through these drains.
• Drains are secured and the muscle layers and fasciae are approximated to close
the necrosectomy incision.
4 Acute Pancreatitis: Surgical Therapies
71
• Given the contaminated eld and incision site, the skin of the incision is left open
for wet-to-dry dressing change.
• If bilateral VARD procedure is to be performed at the same time, the patient is
repositioned with the left lateral decubitus position and a similar procedure is
performed on the contralateral side. However, if the patient cannot tolerate bilat-
eral VARD, the contralateral side is deferred for later.
Pneumo-Retroperitoneum-Assisted VARD (PRA-VARD) Procedure Steps
(Figs.4.6 and 4.7c).
• Procedure is done under general anesthesia. Initial steps are similar to standard
VARD procedure.
• For unilateral VARD procedure, usually the left side, the patient is positioned in
a right lateral decubitus position. The modications of the VARD procedure into
PRA-VARD procedure include the following steps:
• A ank incision measuring at least 6–7.5cm is made on either side of the drain
exit site (Fig.4.7c, part A).
• The drain is used as a guide to extend the incision deeper all the way into the
necrosis cavity, with entry into the cavity conrmed by immediate release of
purulent, often foul-smelling uid. The uid portion of the cavity contents is
suctioned out. The percutaneous drain is removed.
• A single incision laparoscopic device with wound protection device and cap to
allow for multiport placement is then used to establish pneumo-retroperitoneum.
The green ring of the small- or medium-sized wound retractor is inserted through
the incision and deployed into the necrosis cavity. The white ring is then rolled
inwards until the wound is fully retracted (Fig.4.7c, part B).
• The wound protection device is then placed over the white ring and locked
in place.
• One 12mm, and two 5mm balloon laparoscopic trocars are placed through the
cap and insufation is connected to establish pneumo-retroperitoneum.
• A 30° laparoscopic is then used to visualize the interior of the cavity and guide
the necrosectomy.
• Laparoscopic grasping instruments are used to sequentially remove any loose
and loosely adherent necrosis tissues from the cavity (Fig.4.7c, part C).
• Any rmly adherent tissue should be left in place to avoid debridement of viable
tissue and avoid signicant bleeding.
• Once debridement of loose necrosis tissue is completed, a cavity lavage with
saline is performed with laparoscopic suction irrigation.
• The cap, trocars, and wound protector are removed and large bore surgical drains
are placed into the cavity.
• Drains are secured and the muscle layers and fasciae are approximated to close
the necrosectomy incision.
• Given the contaminated eld and incision site, the skin of the incision is left open
for wet-to-dry dressing change.
72
O. Alser et al.
• If bilateral PRA-VARD procedure is to be performed at the same time, the patient
is repositioned with the left lateral decubitus position and a similar procedure is
performed on the contralateral side. However, if a patient cannot tolerate bilat-
eral PRA-VARD procedure, the other size is deferred for later.
Advantages of PRA-VARD procedure over the standard VARD procedure
include:
• Closed space pneumo-retroperitoneum insufation allows for a wider space-
creation in the necrosis cavity, providing excellent visualization to ensure a more
thorough, non-blind and potentially safer necrosectomy compared to standard
VARD where such insufation cannot be achieved (Fig.4.6b).
• The GelPort® system allows placement of three trocars in a triangulating fashion
to allow for an easier procedure with less instrument collision.
Pitfalls of VARD and PRA-VARD Procedures
• Pancreatico-cutaneous stula
• Bowel perforation with enterocutaneous stula
• Vascular injury to surrounding mesenteric vessels with acute intraop- or postop-
erative major bleeding
• Wound dehiscence and complications
Sinus Tract Necrosectomy
This was originally described by Carter etal. [32]. It is a form of minimally invasive
necrosectomy that is akin to the standard VARD procedure but differs from the latter
in the way the necrosis cavity is accessed.
Pre-procedure preparation is similar to VARD procedure as described above.
Sinus Tract Necrosectomy Procedure Steps
• Image-guided percutaneous catheter placement to the infected necrosis always
precedes sinus tract necrosectomy.
• The drainage catheter tract is then serially dilated with increasing size of cathe-
ters until a 30 French catheter size is reached (10mm diameter tract).
• A nephroscope is then used through this tract to enter the infected necrosis cavity
and provide visualization for necrosectomy.
• Grasping laparoscopic instruments are then used to remove loose and loosely
adherent necrotic tissues.
• Large bore surgical drain (s) is placed into the cavity for post-procedure lavage.
• Compared to standard VARD or PRA-VARD procedures, a limited extent of
necrosectomy is achieved by a single sinus tract necrosectomy and usually mul-
tiple (3–6) sinus tract necrosectomy procedures are needed.
• If complete or adequate necrosectomy cannot be achieved, sinus tract necrosec-
tomy can be converted to a standard VARD or PRA-VARD procedure.
4 Acute Pancreatitis: Surgical Therapies
Pitfalls of Sinus Tract Necrosectomy
• Pancreatico-cutaneous stula
• Bowel perforation with enterocutaneous stula
• Vascular injury to surrounding mesenteric vessels with acute intraop- or postop-
erative major bleeding
• Wound complications
73
Minimally Invasive (Laparoscopic andRobotic)
Trans-Abdominal Necrosectomy
As discussed above, the retroperitoneal approach is the preferred approach to necrosectomy whenever feasible. However, in some cases, the location of the infected
necrotizing pancreatitis cavity makes a retroperitoneal approach impractical and not
feasible.
A trans-abdominal approach is the best option for infected necrosis cavities that
are predominantly located in or extending to the anterior peritoneal cavity, with
associated lateral and posterior displacement of the alimentary tract and other intraabdominal organs (Figs.4.4c and 4.8a–c). Given the origin of the necrosis in the
lesser sac, the stomach is usually displaced anteriorly and cephalad while the transverse colon and transverse duodenum may be displaced caudad. In these cases, the
retroperitoneal organs (kidneys, spleen, adrenals, etc.) remain in their usual location
or may be laterally displaced.
As a result, a trans-abdominal approach provides the easiest access to the cavity.
Transperitoneal necrosectomy can be accomplished by open, laparoscopic or
robotic approach, depending on the available resources and surgeon’s expertise
and skills.
Our approach is a minimally invasive approach, with robotic trans-abdominal
necrosectomy.
Pre-procedure Preparation Pearls for Minimally Invasive (Robotic/
Laparoscopic) Trans-Abdominal Necrosectomy Procedure
• Assess the patient’s condition and the ability to tolerate general anesthesia and
operative necrosectomy.
• A thorough review of updated imaging should be done to ensure the necrosis
cavity has developed a mature wall around it to facilitate a safe necrosectomy.
• The relationship between the necrosis cavity and the stomach, transverse colon,
duodenum, and small bowel should be reviewed to guide the approach to
necrosectomy.
Robotic Necrosectomy Procedure Steps
• Since most of these infected necrosis collections are in the midline abdomen, the
patient is positioned supine.
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O. Alser et al.
a
b
c
Fig. 4.8 The endoscopic cystogastrostomy stent is shown on CT done 2weeks following EUSguided cystogastrostomy procedure, showing incomplete drainage the cavity due to residual solid
necrosis tissue (a). The stent was removed without endoscopic necrosectomy, and patient was
discharged. The patient returned 3weeks later with infected necrosis with sepsis, nausea, and
emesis, with CT showing necrosis with air pockets (b). Patient underwent trans-abdominal robotic
necrosectomy with cystogastrostomy. Postoperative day 7 CT showed near-complete resolution of
the cavity (c)
• Trocar placement is variable depending on the location of the cavity and patient
habitus; generally, a mid or lower abdominal placement is feasible, with four
robotic trocars and a 12mm assistant trocar placed in a transverse line across the
abdomen. Placement should be such that access to the furthest extent of the cav-
ity (usually the lesser sac region) can be reached.
4 Acute Pancreatitis: Surgical Therapies
75
• For large lesser sac collections displacing the stomach anteriorly, access to the
cavity can be reached through the lesser sac or through a trans-gastric route.
• We often use a lesser sac approach through the gastrocolic ligament. The gastro-
colic ligament is divided with an energy device. This is usually thickened and
foreshortened due to peripancreatitis.
• Intraoperative ultrasound is performed to localize the infected necrosis cavity
and guide the choice of the best site for a subsequent “cavitotomy.”
• The cavitotomy should be created next to the posterior wall of the greater curva-
ture of the stomach. Once the ideal site for a cavitotomy is chosen, the posterior
wall of the stomach is exposed adjacent to the site chosen for cavitotomy.
• A cavitotomy is made with electrocautery hook/scissors or ultrasonic energy
device and the infected pus is suctioned out of the necrosis cavity by the bedside
assistant.
• A gastrotomy is made adjacent to the cavitotomy and an endoscopic stapler is
used to create a large (preferably 60mm) cystogastrostomy.
• Robotic graspers are used to remove loosely adherent necrosis tissue from the
cavity, which is collected and contained on a sponge.
• Once necrosectomy is completed, the cavity is irrigated and the robotic camera
may be used to visualize the interior of the cavity to conrm complete necrosec-
tomy, drainage of pus, and hemostasis.
• The common cysto-gastric opening is then closed with a 3–0 barbed absorbable
suture to complete the cystogastrostomy.
• If the necrosis cavity is not adjacent to the gastric wall to allow for cystogastros-
tomy, a cystojejunostomy can be performed if it is adjacent to the jejunum, simi-
lar to Fig.4.3.
• If the necrosis cavity is not adjacent to the alimentary tract to allow for a cysto-
gastrostomy or cystoenteric anastomosis, the debrided and drained cavity can be
plugged with vascularized omentum and a surgical drain placed in it.
• The laparoscopic approach follows the same steps as the robotic approach
detailed above. The difference lies in the trocar placement which should be cho-
sen to allow for adequate triangulation and access.
• A minimally invasive trans-gastric approach to necrosectomy may also be used
where the stomach is displaced anteriorly and therefore covers the anterior
surface of the cavity. In this case, after ultrasound is performed to conrm poste-
rior location of the cavity, an anterior gastrotomy is made with an ultrasonic
energy device.
• Ultrasound is then used over the posterior gastric wall to ensure absence of sig-
nicant vasculature posterior to the posterior gastric wall and apposition of the
posterior gastric wall and the cavity wall.
• The necrosis cavity is accessed through a posterior gastrotomy and a stapled
cystogastrostomy is created.
• Necrosectomy is then completed as the cavity is managed as detailed above.
• The anterior gastrostomy is then closed with a stapler or suture closure.
76
O. Alser et al.
Minimally Invasive Necrosectomy Procedure Pitfalls
• Gastrocutaneous stula
• Pancreatico-cutaneous stula
• Gastroduodenal or splenic artery injury/pseudoaneurysm with subsequent gas-
trointestinal or intra-abdominal bleeding
• Colon or small bowel injury and stula
• Wound complications including infection and dehiscence
Open Necrosectomy
Open necrosectomy had been the only procedure for infected necrosis for several
decades. However, due to the high morbidity (up to 95%) and high mortality rates
(10–40%) [20], as well as the dramatic evolution of percutaneous, endoscopic, and
minimally invasive drainage techniques, it is reserved for cases that are not amenable to, or who do not respond to these other interventions. These contemporary
approaches are associated with better outcomes and are now considered rst for
management of necrosectomy if feasible and resources allow, prior to considering
open necrosectomy.
Open Necrosectomy Procedure Details
• A supine position is usually adequate for a trans-abdominal necrosectomy.
• Most necrosis cavities can be accessed through an upper midline incision. Rarely,
a bilateral subcostal incision is needed.
• Access to the necrosis cavity can be gained through the lesser sac or through a
trans-gastric approach, depending on the relationship of the stomach to the
necrosis cavity.
• If the stomach overlies the anterior surface of the infected necrosis cavity, a
trans-gastric approach is used through an anterior gastrostomy followed by
ultrasound- guided posterior gastrotomy and cavitotomy, necrosectomy, and
drainage of the cavity, and with stapled cystogastrostomy. The anterior gastrot-
omy is then closed.
• If the necrosis cavity is adjacent to the jejunum, a cystojejunostomy is performed
instead after necrosectomy.
• If the cavity is not adjacent to the stomach or small bowel, it is plugged with
vascularized omentum and drains placed.
• If the cavity is adjacent to the mesocolon, debridement and drainage occur
through the mesocolon. Attention should be made to the blood supply to avoid
inducing ischemia to segments of the colon. Colectomy may be necessary at the
time of surgery in difcult cases.