Videoscopic Assisted Retroperitoneal Debridement for infected necrotizing pancreatitis

This is a 43 year old male with infected necrotizing pancreatitis that will undergo a physioscopic assisted retroparitoneal debrightment or a fart procedure. Two weeks before this procedure, two large bore percutaneous drains were placed in the peri-pancreatic collection. Here you see those two drains exit from the left flank and over the left pelvic rim. The patient is placed in a supine position with the left side 30 degrees elevated. A 5 to 7 centimeter subcostal incision is made in the left flank. With help of the CT images and by following the percutaneous drain, the subcutaneous tissues

and the fascia are dissected and we enter the retroparitoneal peri-pancreatic collection. The patient is placed with a regular suction device and the pus encountered is removed and then two long simpatectomy hooks are inserted in order to keep the incision open. We then insert a regular 0 degree elliposcope and remove the first necrosis encountered on the direct side with the use of long grasping forceps. Having the percutaneous drain deeper into the cavity, parts of loosely adherence necrotic material are removed. Gently pulling, we remove the necrotic tissue. The suction device may be helpful in removing any fluid obstructing the view.

Completely cosectomy is not the ultimate aim of this procedure. Only loosely adherent pieces of necrosis are removed, thereby keeping the risk of tearing underlying blood vessels to a minimum. In the rare case of extensive bleeding, the retroparitoneal cavity can be easily packed, either waiting the bleeding to definitely stop or to act as a bridge to angiographic coiling. This patient is now six weeks after onset of disease. We always try to postpone surgical intervention, if possible up to 30 days. On the left side of the collection you can see the percutaneous drain.

This patient worked well for two weeks, but when the patient deteriorated again, it was decided to perform the farce procedure. A big advantage of fart over pure endoscopic transgastic or percutaneous techniques is that with fart it is possible to remove big chunks of necrotic material via the incision. Here you see such a large chunk of necrotic pancreas being removed. With the leproscopic tools we can see which parts of the necrosis are loosely adherent. If we find them, those pieces are removed. So the surgeon is holding the leproscope in his left hand and a regular rinsing device

in his right hand. When all the necrotic material is removed, we clean out the cavity. On the endoscopic image you can see the two drains in the cavity. After the incision is closed, these drains are left inside too and act as a continuous post-operative lavage system. We increase the lavage fluid up to 10 liters of saline per 24 hours.

In this case we use a low pressure pulse lavage system and the end of the operation to remove the last chunks of necrosis and pus. This was the necrosis removed during the procedure. The fart was performed via a 6 cm incision which was closed and continuous post-operative lavage started immediately.