Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess

Summary

To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

Abstract

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

Introduction

The treatment of severe acute pancreatitis (SAP) complicated by peripancreatic infection and necrosis has long been a difficult problem to solve^1,2. Pancreatic infection and necrosis are serious complications of severe acute pancreatitis³. Reducing abdominal and retroperitoneal pressure, removing necrotic tissue as much as possible, and reducing the absorption of toxic substances are the main surgical principles for successfully treating SAP⁴. Traditional open surgery and continuous postoperative lavage have saved the lives of many SAP patients. However, the transabdominal approach requires perforation of the gastrocolic ligament, entry into the minor omental sac, and subsequent invasion of all segments of the pancreas, which inevitably interferes with various abdominal organs and might introduce retroperitoneal bacteria into the abdominal cavity, increasing the risk of abdominal infection. In addition, the drainage tube is drained from the retroperitoneal cavity to the outside of the abdominal wall. Owing to poor drainage, compression of the intestinal tube may also cause intestinal fistula and abdominal bleeding. In 2013, the Evidence-based Guidelines for the Treatment of Acute Pancreatitis issued by the International Society of Pancreatology and the American Society of Pancreatology noted that minimally invasive debridement of necrotic tissue was superior to open debridement for patients with symptomatic infectious necrosis⁵. Chen et al.⁶ used peritoneal laparoscopy to reach the peritoneum, remove necrotic pancreatic tissue, and place the drainage tube, achieving satisfactory results. However, theoretically, problems such as bacterial displacement and peritoneal infection caused by communication between the peritoneum and retroperitoneum are inevitable. Sileikis et al.⁷ used three-hole laparoscopic retroperitoneal resection of pancreatic necrotic tissue and catheter drainage from 2007 to 2009 and cured 8 SAP patients.

Since 2016, we have adopted retroperitoneal laparoscopy to remove necrotic pancreatic tissue through a retroperitoneal approach. Compared to other minimally invasive surgeries, this method is more direct and safer. It provides direct access to the retroperitoneal space, allowing direct visualization and removal of necrotic tissue in the renal capsule. The field of view is clear, bleeding is easily controlled, and a drainage tube can be placed as needed, ensuring effective drainage. The drainage tube does not pass through the abdominal cavity, causing minimal disturbance to the cavity and reducing the risk of abdominal infection. The necrosis and infection of SAP occur mostly in the tail of the pancreas. There is often necrosis of the peripancreatic fatty tissue, which sometimes extends into the left colonic sulcus. Therefore, we utilized a left-sided approach in all patients, and typically, a single surgery was sufficient to thoroughly remove the necrotic tissue. We believe that retroperitoneal laparoscopic surgery via a left-sided approach is particularly suitable for patients with necrosis of the pancreatic body and tail combined with massive effusion.

Protocol

The protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Meizhou People's Hospital. (MS-2023-C-95). Informed consent was obtained from patients for this study. 1. Patient selection Use the following inclusion criteria for patients: meet the clinical diagnosis of acute pancreatitis; age between 18 and 80 years; have a CT-enhanced scan grade D/E; and a substantial amount of necrotic tissue and fluid acc…

Representative Results

A total of six patients received this surgical treatment (Table 1). Preoperatively, all patients were assessed based on PaO2/FiO2, systolic blood pressure, and creatinine levels and were assigned modified Marshall score10 and APACHE II scores (Table 2). All patients underwent surgery smoothly, and the duration of surgery ranged from 75 to 100 min, with an average of 84 ± 6.7 min. Preoperative bacterial cultures obtained through PCD tubes…

Discussion

The optimal timing of surgical intervention for SAP has been a subject of ongoing debate. In the past, surgical intervention was assumed to be performed immediately upon the occurrence of pancreatic infection-related necrosis. However, since 2000, an increasing number of experts have suggested that the timing of surgical intervention for SAP should be postponed as much as possible^11,12,13. Aseptic peripancreatic necrosis may not…

Materials

Dissecting forceps	KANGJI	ZP485RB 330mm×Φ5
Drainage tube	Kang-Li	QH-F28
Grasping forceps	KANGJI	ZP531RB 330mm×Φ5
Laparoscope	STORZ	26003BA
Normal Saline 3000ml	Ke-Lun	3000ml:27g
Suction and Irrigation	KANGJI	Φ5/Φ10×330mm
Suture	ETHICON	SA86G
Trocar	KANGJI	ZP015RN Φ5.5/ ZP018RN Φ12.5
Ultrasonic knife	An-He	AH-600
Veress needle	KANGJI	ZP001RN Φ2.5×100mm