Clinical Pancreatology for Practising Gastroenterologists and Surgeons. Группа авторов
this approach has been claimed to be the standard for WON in the left pancreas, real data on patient outcomes is scarce and limited to case series [14,30,31], which still report a mortality of up to 40%. The technique is also not exempt from complications, such as colonic fistula, gastric and duodenal perforation, enteric fistula, pancreatic fistula, and retroperitoneal hemorrhage, and therefore should be confined to centers with an appropriately experienced multidisciplinary team.
Figure 15.2 (a) Infected pancreatic necrosis by abdominal tomography. (b) Placement of a retroperitoneal percutaneous catheter in pancreatic lodge. (c) Position of the patient for video‐assisted retroperitoneal debridement (VARD). (d) After VARD, a 32‐Fr drain is placed in the pancreatic lodge to enable continuous flushes.
Source: courtesy of Patricia Sánchez‐Velázquez.
Laparoscopic Transperitoneal Approach
This procedure is the least used minimally invasive approach. Its main drawback is that the patient must be in a stable clinical condition to allow adequate tolerance of pneumoperitoneum. Furthermore, the large inflammatory component of omental and mesenteric fat may hinder access to the lesser sac and retroperitoneum and preclude correct drainage of the pancreatic lodge.
The laparoscopic transperitoneal approach achieves a lower overall complication rate than conventional open necrosectomy (particularly with regard to pancreatic fistula), fewer wound infections, and a shorter postoperative stay. Based on the data reported in the literature, 80% of these cases will not require additional surgical procedures. Open conversion is below 20% [32] while the reported mortality rate is close to 10%. However, most published studies include retrospective series of less than 10 selected patients and as many do not include relevant data their results should be assessed with caution [33,34].
The technique is always performed under general anesthesia. It consists of a conventional exploratory laparoscopy with three or four ports, reaching the pancreatic lodge to complete the necrosectomy and inserting large‐caliber drains in order to continue with postoperative lavages. The preferred route for accessing the pancreatic cell is via the gastrocolic ligament and greater omentum (Figure 15.3). In a variant of this technique, a device is used for hand‐assisted surgery (GELport) to allow necrosectomy by digital blunt dissection.
Laparoscopic transgastric necrosectomy is a particular variant of this approach. This technique follows the same principle as endoscopic necrosectomy but uses a laparoscopic approach. WON located retrogastrically is deemed to be ideal for this approach, given its close contact with the gastric posterior wall [35].
The patient is placed in the decubitus position and intervention is carried out under general anesthesia. Entry into the peritoneal cavity and ports are the same as the previously described intervention and gastrotomy is performed (Figure 15.4b) at the level of the necrosis located by intraoperative ultrasonography. Needle aspiration is performed for both anatomical confirmation and to obtain intraoperative cultures (Figure 15.4c). A wide posterior necrosectomy is then performed by electrocautery to access the necrotic tissue. Blunt debridement of the necrosis is carried out (Figure 15.4d) and as much as possible of the necrotic debris is removed directly. The posterior gastrotomy is left open to drain the necrotic cavity and the anterior wall gastrotomy is closed by an intracorporeal suture.
Figure 15.3 Laparoscopic transperitoneal approach. (a) Location of the necrosis by CT scan. (b) Necrosis is reached via the gastrocolic ligament and greater omentum. (c) Drains are placed as shown. *, Peripancreatic retropneumoperitoneum; **, greater curvature of the stomach; ***, pancreatic necrotic collection.
Source: courtesy of Patricia Sánchez‐Velázquez.
Figure 15.4 Laparoscopic transgastric necrosectomy. (a) CT scan diagnoses a retrogastrically placed walled‐off necrosis. (b) Gastrotomy with harmonic device. (c) Location of the necrosis by punction. (d) Necrosis drained by dividing the posterior gastric wall.
Source: courtesy of Patricia Sánchez‐Velázquez.
Although there is not enough robust data to recommend this technique over the others, it does have some advantages in that it overcomes the limitations of endoscopic necrosectomy, such as a lower cost than lengthy treatments with repeated interventions.
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