Minimally Invasive Pancreatic Debridement: Intracavitary and Transperitoneal Debridement

Pancreatic debridement is necessary for treatment of infected pancreatic necrosis but is associated with significant morbidity that includes a high incidence of wound complications and enterocutaneous fistulae. We demonstrate two minimally invasive techniques of pancreatic debridement: catheter-guided intracavitary debridement and laparoscopic transperitoneal debridement.

In the first patient, fine needle aspiration of a heterogeneous lesser sac collection confirmed a diagnosis of infected pancreatic and peripancreatic necrosis. Under CT guidance, two widely spaced percutaneous drainage catheters were placed into the lesser sac collection. On the following day, the patient was taken to the operating room. Through his left-sided catheter a guide wire was passed, and the catheter was removed. First a dilator was passed over the guide wire, and then the dilator was passed through a 5 mm port and together this assembly was passed over the guide wire. The guide wire and dilator were removed, carbon dioxide was insufflated, and a laparoscope was inserted and confirmed placement of the port within the lesser sac cavity. The second catheter was identified, and using a guide wire was exchanged for a second port. Using these two ports, fluid was evacuated from the lesser sac and debridement of extensive necrotic tissue was completed. After there was no additional debridement to perform, the ports were replaced with two drains. Subsequent x-rays confirmed thorough debridement of the pancreatic and peripancreatic tissues.

In the second patient, gas bubbles were identified in an extensive lesser sac collection. A 12 mm port was placed using an open technique, and then two left sided 5 mm ports were placed. The gastrocolic ligament was divided, and the stomach was gently elevated. Because of the ongoing inflammatory process, the usual planes posterior to the stomach were obliterated, but with careful dissection along the posterior surface of the stomach, the dissection could be carried downward toward the lesser sac and pancreatic bed. As the dissection was continued downward, an abscess cavity containing a large amount of purulent fluid was entered. After evacuating the fluid, the opening into the lesser sac was enlarged and the stomach was elevated anteriorly, allowing visualization of the lesser sac and the pancreatic and peripancreatic tissues. Under direct vision, debridement of the necrotic pancreatic and peripancreatic tissues was performed. Additional collections of purulent fluid and necrotic tissue were identified, drained, and debrided. After no further collections could be identified and no further necrotic tissue could be debrided, the lesser sac was copiously irrigated, and drains were positioned in it. Follow up CT scans showed that the debridement had been thorough, and the patient subsequently recovered uneventfully.

These two cases illustrate two minimally invasive methods of accessing the lesser sac and pancreatic bed to perform pancreatic and peripancreatic debridement. These approaches minimize the potential for wound and fistula complications associated with debridement procedures performed through a standard laparotomy incision.

Session: Podium Video Presentation

Program Number: V034

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