Minimally invasive approach to pancreatic necrosectomy

Conventional open surgery for infected pancreatic necrosis is associated with significant surgical morbidity, that is, wound complications, facial dehiscence, and intestinal fistulae. In recent years, there has been interest in attempting to reduce this surgical morbidity by adopting a number of minimally invasive approaches.

Fifteen patients with pancreatic necrosis underwent pancreatic necrosectomy by minimally invasive surgery (11 men, 4 women; age group: 25-64 years, mean age: 46 years). Apache II scores ranged from 5 to 14. Pancreatic necrosectomy was performed by laparoscopic transperitoneal approach in 12 patients (transmesocolic, 4 patients; transgastrocolic, 6 patients; and gastrohepatic omentum, 2 patients), by retroperitoneal approach in 2 patients, and by a combination of methods in 1 patient (endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy). Relook laparoscopy was done in 5 patients to assess for residual necrosis.

All the patients tolerated the procedure well, and there was no mortality. Two of them had pancreatic fistula, which eventually responded to conservative treatment. Three patients were converted to open necrosectomy because of bleeding or difficulty to access the area of necrosis. The mean operating time was 120 ± 10 minutes. There were no postoperative complications related to the procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The average length of hospital stay after surgery was 14 days.

Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results available, either with open surgery or among different minimally invasive techniques.