A Hybrid VARD Approach to Infected Acute Necrotic Collections

Abstract

Infected acute necrotic collections (ANC) are a complication of acute pancreatitis that routinely require early drainage procedures. The “step up” approach has gained acceptance as the preferred paradigm for infected ANC. With this approach, open necrosectomy is avoided in favor of percutaneous drainage followed by video assisted retroperitoneal debridement (VARD). We describe a novel hybrid VARD technique. For patients meeting criteria for step-up procedure, a percutaneous drain is placed into the collection using a left retroperitoneal approach. If serially upsizing this drain does not resolve the infection, a VARD is performed. Traditionally this is done by cutting down along the drain tract with a small incision until the necrotic cavity is reached, allowing VARD. However, a majority of patients at our institution have a high BMI, making approaching the collection via a minimally invasive cutdown difficult. We made 2 modifications to the existing technique. First, we use a 12 mm optiview® trocar loaded with a 0-degree camera inserted alongside the drain track through an small incision. The camera is advanced into the collection using the drain as a horizon. Pneumoperitoneum is insufflated, additional trocars placed, and necrosectomy completed. Second, for complex geographic collections we upsize to a 15 mm trocar and use a flexible endoscope to delineate the edges of the necrosis and remove free necrosum using a Roth net device. Closure is accomplished with drains and occasionally vacuum assisted devices. Using these techniques, we have been able to manage complex infected necrosis in morbidly obese patients with good results.