Minimally invasive retroperitoneal necrosectomy: how do we do it?

Abstract

: Acute pancreatitis (AP) is an inflammatory condition that includes local and systemic manifestations, showing a mild behavior in most patients. Infected pancreatic necrosis is the most aggressive scenario with a high mortality rate. According to the PANTER trial, the “step-up approach” has shown a lower rate of new-onset organ failure compared with open necrosectomy. Whenever possible, major surgical interventions in infected pancreatitis should be delayed as long as possible, ideally until the fourth week since the onset of symptoms. The selection and timing of the procedure are key points, taking into account the clinical condition of the patient, the location, the availability of equipment, and the experience of the surgical team. The technical description of the laparoscopic retroperitoneal necrosectomy is presented focused on the path to the retroperitoneum, anatomical aspects, and tips and tricks. Furthermore, the step-up approach flowchart, indications, contraindications, patient’s workup, post-operative management, advantages, complications, and technique video are included. Although laparoscopic necrosectomy requires mastery of retroperitoneal anatomy and good laparoscopic skills, it is an exceptional tool for the surgeon within the arsenal for this difficult and serious condition. The authors have adopted the laparoscopic retroperitoneal necrosectomy as part of the step-up approach and have found it very replicable and ergonomic.