Cici Zhang, MD, Jonathan Wong, MD. Lenox Hill Hospital
This is a 42 year-old morbidly obese male presented with severe necrotizing gallstone pancreatitis. The patient experienced continued clinical deterioration despite endoscopic decompression of the biliary duct. Given the retroperitoneal location and the walled off nature of the peripancreatic fluid collection, we elected to perform laparoscopic assisted retroperitoneal necrosectomy. Prior to operative debridement, percutaneous drainage was performed with a 14F pigtail drain into the tail of the pancreas. The purpose of percutaneous drainage was twofold: one to sample the necrotic pancreas and, more importantly, to direct the operative entry to the retroperitoneal space. We entered the abdomen by making a 3-inch incision was between the 10th and 11th ribs. as you can see, we encountered a significant amount of necrotic debris and approximately one liter of purulence. This approach has significant advantages as well. These include faster return of GI function, less pain, well tolerated by patients which allow for repeated debridement, and avoid morbidity associated with an open abdomen. Limitations of the retroperitoneal approach include unfamiliarity of the retroperitoneal space. The splenic vessels are exposed and friable which makes them prone injury if they are patent at the time of the debridement. The left kidney, posterior stomach, large and small intestine form the walls of the this space. Another limitation of this approach is the inability to access the head of the pancreas, especially in obese patients. Once hemostasis was achieved, two penrose drains were left in place. The patient tolerated the procedure well.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79809
Program Number: V194
Presentation Session: Video Loop
Presentation Type: VideoLoop