Video-assisted retroperitoneal pancreatic debridement: A video-based guide to the technique

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Acute pancreatitis is a common diagnosis with an incidence of 13 to 45 of 100,000 people and leads to about 270,000 annual hospital admissions in the United States.1 The majority of cases are mild and self-limited, but about 20% will present with or develop severe pancreatitis with some component of pancreatic necrosis.2,3 It is critical to recognize the presence of necrotizing pancreatitis (NP), as this will drastically change the treatment algorithm and also places the patient in a much higher category of risk for both complications and mortality.4 Traditionally, the diagnosis of NP, and particularly infected pancreatic necrosis, mandated an immediate open laparotomy and extensive pancreatic debridement with necrosectomy.3,5 However, subsequent experience and small published series have demonstrated that (1) infected NP does not necessarily mandate an immediate laparotomy, and (2) outcomes are markedly improved if the surgical intervention can be performed in a delayed fashion (>4 weeks) to allow for the formation of well-delineated “walled-off necrosis” (WON).5–8
A relatively newer and highly successful approach to NP that utilizes these two principles is known as “the step up approach”.9 This involves IV antibiotics followed by percutaneous drainage of the infected necrosis. If there is no clinical improvement, then a second attempt at percutaneous drainage may be performed, along with drain upsizing to larger bore catheters. About one-third of these patients will require no further intervention; however, if there is no clinical improvement after a second percutaneous drain and/or upsizing, then the patient is taken for surgical debridement. The currently preferred surgical debridement in this approach is NOT an open approach via laparotomy, but utilizes a minimally invasive flank approach known as video-assisted retroperitoneal debridement (VARD).2,10,11 In addition to avoiding open surgery, the step-up approach avoids the need for multiple endoscopic procedures, sinograms or fistulagrams, and prolonged antibiotics. We believe this to be a generally superior approach to open necrosectomy and present a description of our recommended approach with technical details and accompanying video clips to highlight these techniques (see Video, Supplemental Digital Content 1, Written informed consent, including permission to record and use the included video clips, was obtained from all patients included in the video clips.
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