In any surgical approach to necrotizing pancreatitis, the goal is to remove the necrotic tissue and to minimize accumulation of exudative fluid and extravasated pancreatic exocrine secretions. Reoperation in this setting can be difficult and can lead to increased morbidity. The principle of necrosectomy and "closed packing" is to perform a single operation, with thorough debridement and removal of necrotic and infected tissue, while minimizing the need for reoperation or subsequent pancreatic drainage.
For most patients, a midline incision allows better exposure and optimal placement of drains.
The transverse colon is elevated anteriorly and access to the lesser sac is gained via the left mesocolon. When necrosis is extensive, often there is bulging of the necrotic process at this site and entry should be made bluntly with a clamp or finger. Fluid is evacuated and sent for culture.
The opening is enlarged, and with two fingers the cavity is explored. Depending on the extent and location of necrosis, an incision can also be made in the right mesocolon and, if necessary, the middle colic vessels are clamped and ligated.
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