Laparoscopic Transgastric Pancreatic Necrosectomy and Cystgastrostomy

Diagnostic laparoscopy is performed and confirmed the pancreatitis. It shows saponification of the pancreas. Laparoscopic intraoperative ultrasonography confirmed CT scan findings and determined the most accessible pathway to the cyst. An anterior wall gastrotomy is then performed and extended to 5 cm length. The cyst is then aspirated through the posterior stomach wall followed by posterior wall gastrotomy. A linear 60 mm stapler is used to staple posterior stomach wall to the anterior cyst wall. Extensive pancreatic necrosectomy is done and the area is irrigated with normal saline. Closure of the anterior gastrotomy is then achieved and the necrotic tissue is placed in a pouch and extracted. Operative time: 125 minutes, EBL: 50 ml. The patient was out of bed the evening of surgery. She also tolerated oral intake on postoperative day 3 after removing the nasogastric tube. She was then discharged on postoperative day 5. Pathology: Necrotic pancreatic tissue.

Indications for pancreatic necrosectomy: 1.Infected pancreatic necrosis 2.Severe acute pancreatitis and necrosis associated with hemodynamic changes with no response to resuscitative measures 3.Significant symptoms like persistent abdominal pain 4.¢Walled off¢ necrosis preferably at least 4 weeks following an acute pancreatitis episode. 5.Compression on the surrounding structures: gastric outlet or biliary obstruction, bleeding or fistulizing into the surrounding organs 6.Abdominal compartment syndrome Indications for Laparoscopic Approach: 1.Stable patients with well-organized necrosis 2.Simultaneous Laparoscopic cholecystectomy in patients with biliary pancreatitis

Contraindications for Laparoscopic Approach: 1.Unstable patients 2.Early cyst formation (less than 4 weeks from pancreatitis episode) 3.Previous multiple abdominal incisions (a relative contraindication) 4.Absence of good abutment of cyst wall to the posterior stomach wall (transgastric approach)

The patient is placed in a supine position. The surgeon stands on the patient¢s right side and two assistants on the left side. A Veress needle is placed in the upper abdomen and CO2 pneumoperitoneum is obtained. Four trocars are placed in a crescent fashion along the left costal margin. A 5mm trocar in the epigastric area, a 10 mm trocar midway between xiphisternum and umbilicus, a10 mm trocar at the left midclavicular area and a 5 mm trocar at the left anterior axillary line.

1.CT scan of the abdomen, pancreas protocol 2.Endoscopic ultrasonography (EUS) may facilitate endoscopic drainage in the absence of extensive necrosis. 3.General labs including complete blood count, serum electrolytes, creatinine, glucose, albumin and prealbumin.

1.Percutaneous retroperitoneal drainage with or without endoscopic assistance is an option which could be used before a more extensive procedures 2.Trans-oral (NOTES) approach is a useful approach for patients with limited necrosis 3. Laparoscopic access is performed with hand-assisted or totally laparoscopic approach, or alternatively by creation of a cyst-enterostomy via a transgastric or retrogastric approach. 4.Complete necrosectomy is possible with laparoscopic approach. This may need good exposure of the cyst contents. The approach should give access to the head of pancreas if needed. 5.Caution should be taken to avoid injuring splenic vessels especially in patients who need extensive and deep debridement. 6.The necrotic material should always be extracted through an endopouch. Ample saline irrigation of the pancreatic bed is always needed. 7.Conversion to open approach is vital in case of uncontrollable bleeding, unstable patient and failure of laparoscopic approach.

Advantages of Laparoscopic Approach: 1.Laparoscopic approach has specific benefits over open approach: -Less intraoperative blood loss -Less pain -Cosmetic benefit (smaller incisions) -Less incidence of incisional hernia -Less incidence of wound infection -Earlier return to normal activities of daily living 2.Laparoscopic transgastric necrosectomy approach via cyst enterostomy has less incidence of major vessels injury. Therefore it is associated with less chance of bleeding and visceral ischemia. 3.Pancreatic fistula is less likely with this approach. 4.Laparoscopic approach can access areas which is not amenable through endoscopic or retroperitoneal access. 5.This approach can give a success rate of up to 95%, but with morbidity of 20% and mortality of 0.18%. Disadvantages: 1.Laparoscopic approach has longer operative time. 2.Laparoscopic approach is not advisable in patients with borderline intraoperative stability. 3.Peritoneal contamination by necrotic and possibly infected material in comparison to endoscopic and retroperitoneal approach.

Complications/Risks of pancreatic necrosectomy: Intraoperative: -Bleeding which necessitates conversion from laparoscopic to open approach. -Inability to obtain complete debridement by laparoscopic approach. Early postoperative: -Bleeding which requires blood transfusion, angioembolization or operative hemostasis. -Multiorgan failure is a common reason for prolonged ICU stay. -Both bleeding and multiorgan failure can lead to a postoperative mortality which can reach 25%. Late postoperative (Endoscopic or Radiologic approaches could be used to manage most): -Biliary stricture in (6%). -Persistent/recurrent pseudocyst in (8%), -Pancreatic fistula in (13%), -Gastrointestinal fistula in (2%), -Delayed collections in (5%) -Incisional hernia in (2%) -Exocrine insufficiency in (25%). -Endocrine insufficiency in (33%) -Long hospital or ICU and hospital stay

Complications/Risks of pancreatic necrosectomy: Intraoperative: -Bleeding which necessitates conversion from laparoscopic to open approach. -Inability to obtain complete debridement by laparoscopic approach. Early postoperative: -Bleeding which requires blood transfusion, angioembolization or operative hemostasis. -Multiorgan failure is a common reason for prolonged ICU stay. -Both bleeding and multiorgan failure can lead to a postoperative mortality which can reach 25%. Late postoperative (Endoscopic or Radiologic approaches could be used to manage most): -Biliary stricture in (6%). -Persistent/recurrent pseudocyst in (8%), -Pancreatic fistula in (13%), -Gastrointestinal fistula in (2%), -Delayed collections in (5%) -Incisional hernia in (2%) -Exocrine insufficiency in (25%). -Endocrine insufficiency in (33%) -Long hospital or ICU and hospital stay

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