Pancreatic necrosectomy is a necessary operation for necrotizing pancreatitis. The traditional open approach has been associated with difficult access and significant negative outcomes including wound complications, pancreatic fistula and prolonged hospital stay. A 57-y-old female patient presented with mild abdominal pain and epigastric fullness.She had a history of multiple episodes of acute pancreatitis and pseudocyst formation. Abdominal computed tomography (CT )scan showed a large pseudocyst of 12×15 cm size compressing the posterior wall of the stomach. Following cystgastrostomy, a large amount of necrotic pancreatic tissue is found and so necrosectomty step was added to the operation.This video demonstrates the technical details during a minimally invasive necrosectomy of the pancreas with an expedited recovery.
DOI: http://dx.doi.org/10.17797/1ms9xzjz24
Editor Recruited By: Jeffrey B. Matthews, MD
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
N/A
1.Connor S, Alexakis N, Raraty MG, et al. Early and late complications after pancreatic necrosectomy. Surgery. 2005 May;137(5):499-505.
2.Van Santvoort HC, Besselink MG, Bakker OJ et al.; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N. Engl. J. Med. 2010;362(16):1491¢1502. Multicenter randomized control trial that demonstrated the superiority of minimally invasive necrosectomy over open necrosectomy.
3.Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut. 2009;58(9):1260¢1266. First multicentric study with long-term follow-up on direct endoscopic necrosectomy.
4.Bakker OJ, van Santvoort HC, van Brunschot S et al.; Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307(10):1053¢1061. A randomized trial comparing open necrosectomy with minimally invasive necrosectomy in patients with infected necrosis.
5.Besselink MG, van Santvoort HC, Nieuwenhuijs VB et al.; Dutch Acute Pancreatitis Study Group. Minimally invasive 'step-up approach' versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg.2006;6,6.
6.Tan JW, Tan H, Hu B, et al. Short-Term Outcomes from a Multicenter Retrospective Study in China Comparing Laparoscopic and Open Surgery for the Treatment of Infected Pancreatic Necrosis. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2012;22(1):27-33.
7.Parekh D. Laparoscopic-Assisted Pancreatic Necrosectomy. Arch Surg. 2006;141:895-903.
8.Fink D, Soares R, Matthews JB, et al. History, Goals, and Technique of Laparoscopic Pancreatic Necrosectomy. J Gastrointest Surg . 2011;15:1092¢1097.
9.Navaneethan U, Vege SS, Chari ST, et al. Minimally Invasive Techniques in Pancreatic Necrosis. Pancreas. 2009 November; 38(8):867-75.
10.Pamoukian VN, Gagner M. Laparoscopic necrosectomy for acute necrotizing pancreatitis. J Hepatobiliary Pancreat Surg. 2001;8:221¢223.
11.Wysocki AP, McKay KJ, Carter CR, et al. Infected pancreatic necrosis: minimizing the cut. ANZ J Surg .2010;80:58¢70.
12.Schmidt CM. Introduction: SSAT/AGA/ASGE State-of-the-Art Conference: Necrotizing Pancreatitis: Novel Minimally Invasive Strategies. J Gastrointest Surg. 2011;15:1086¢1088.
13.De Rai P, Zerbi A, Castoldi L, et al (Italian Association for the Study of the Pancreas). Surgical management of acute pancreatitis in Italy: lessons from a prospective multicenter study. HPB. 2010;12:597¢604.
14.Owera AM, Ammori BJ. Laparoscopic endogastric and transgastric cystgastrostomy and pancreatic necrosectomy. Hepatogastroenterology. 2008 Jan-Feb;55(81):262-5.
Review Laparoscopic Transgastric Pancreatic Necrosectomy and Cystgastrostomy. Cancel reply
Related Videos
Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Laparoscopic Transgastric Pancreatic Necrosectomy and Cystgastrostomy.