Acute pancreatitis (AP) is commonly self-limiting and resolves without serious complications. However, 25% of patients with AP develop a more severe form of the disease and is associated with the development of potentially life-threatening complications like necrosis of the pancreatic parenchyma, the peripancreatic tissue or both.

Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management.

Technique

Patient was positioned in French position. Operating surgeon stands in between the legs of the patient. Camera assistant stands on right side of the patient while first assistant and scrub nurse stands on left side. Monitor was positioned over left shoulder of the patient, closer to midline. Pneumoperitoneum is created after insertion of 12 mm optical trocar infraumbilically. Diagnostic laparoscopy is done. Two lateral pararectal trocars are inserted under vision. Peripancreatic adhesions are released by blunt dissection.

Access to the pancreatic necrotic tissue is decided based on the status and site of the necrosis, as demonstrated by preoperative CECT. Retrogastric approach is preferred in Acute Necrosis. Retrogastric approach may be transgastrocolic or transmesocolic/infracolic approach. In transgastrocolic approach, gastrocolic ligament is opened to access the necrosed tissue. In transmesocolic or infracolic approach, the mesocolon is opened near the suspensory ligament of Treitz, between middle colic artery and left colic artery. It is the preferred approach in necrosis involving tail region of pancreas. Necrotic tissue is dissected and removed using blunt dissection in an endobag. Resultant cavity is washed thoroughly with normal saline and two 24F tube drains are positioned inside the cavity for post-operative lavage.