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Percutaneous drainage of infected pancreatic fluid collections is often unsuccessful. Alternatively, open necrosectomy techniques are very morbid. We hypothesized that in selected cases, laparoscopic techniques could be used to facilitate percutaneous drainage of the residual particulate necrosectum and avoid a laparotomy. We report our experience with laparoscopic assisted retroperitoneal debridement as an adjunct to percutaneous drainage for patients with infected pancreatic necrosis. Case studies were reviewed retrospectively. We analyzed the course of six patients undergoing laparoscopic assisted debridement of infected pancreatic necrosis after failure of percutaneous drainage. With the drains and computed tomography (CT) scan used as a guide, laparoscopic debridement of the necrosectum was performed. Between November 1995 and December 1999, six patients were treated with this method. In four patients, laparoscopic assisted percutaneous drainage was successful. Two patients required open laparotomy. Complications included a self-limited enterocutaneous fistula and a small flank hernia. No deaths occurred. This early, limited experience has demonstrated the feasibility of laparoscopic assisted percutaneous drainage for infected pancreatic necrosis. With this technique, two-thirds of our patients avoided the morbidity of a laparotomy.

Percutaneous drainage has been shown to be an acceptable method for treating both pancreatic abscesses and infected pancreatic necrosis. However, percutaneous techniques have certain shortcomings, including the time and labor required and failure of the catheters to adequately drain the particulate debris. Growing experience around the world indicates that there is a role for retroperitoneal laparoscopy as a means of facilitating the percutaneous drainage of infected pancreatic fluid collections and avoiding a laparotomy. Our technique is discussed in this paper. Once infection is documented in a pancreatic fluid collection by fine-needle aspiration, one or more percutaneous drains are placed into the fluid collection(s). A computed tomography (CT) scan is repeated. If further drainage is indicated, retroperitoneoscopic debridement is performed. Using a combination of the percutaneous drain(s) and the post-drain CT scan, ports are placed and retroperitoneoscopic debridement of the necrosectum is performed under direct visualization. Prior to completion of the operation, a postoperative lavage system is created. Six patients with infected pancreatic necrosis have been treated with this technique. Prior to commencement of our laparoscopic protocol, all six patients would have required open necrosectomy. Four of the six patients were managed with retroperitoneoscopic debridement and catheter drainage alone. Complications included a colocutaneous fistula and a small flank hernia. There were no bleeding complications and no deaths. Although open necrosectomy remains the standard of care for the treatment of infected pancreatic necrosis and pancreatic abscess, there is growing evidence that laparoscopic retroperitoneal debridement is feasible.