Tricks of the Senior Surgeon

Open Necrosectomy with Closed Postoperative Lavage

■ Blunt necrosectomy: necrotic tissue is removed by blunt digital dissection without instruments; use of scissors increases the risk of excising still viable tissue, injuring portal, splenic, or mesocolic vessels, or causing difficult-to-control bleeding.

■ Retroperitoneal necrosis: Even if the necrotic process in the retroperitoneum extends into the pelvis, blunt digital necrosectomy can be performed via an anterior, supra-colic approach through the lesser sac dissecting inferiorly, following the necrosis.

■ Biliary pancreatitis: ERC can be performed before necrosectomy in patients with gallstone pancreatitis, clearing the common duct of stones, and thereby only cholecystectomy is performed with exploration of bile duct omitted, reducing the risk of bile duct injury.

■ Diverting ileostomy: With extension of the necrotic process behind the colon, we often perform a diverting ileostomy to reduce the risk of colonic fistula during the course of disease; intestinal continuity is restored 3months after discharge.

Necrosectomy and Closed Packing

■ Have the recent CT in the operating room. It is your road map to be sure you do not leave collections of necrosis undrained.

■ Bleeding inevitably ensues during the debridement. Unless this is copious, finish the debridement before attempting to stop it. It usually stops spontaneously or with the packing.

Planned Repeated Necrosectomy

■ Resist operating early on patients with necrotizing pancreatitis, even with hemodynamic and metabolic instability. Make every effort to operate as late as possible, even with proof of infected necrosis, provided that the patient remains stable with maximal intensive medical therapy; the necrotizing process will have thus ceased and all viable and devitalized tissue will have defined. In such a case, a single complete necrosectomy and primary abdominal wall closure will be usually enough.

■ Operative planning based on the preoperative CT is of paramount importance. All areas with fluid collections demonstrated on preoperative CT should be sought for, unroofed, and debrided. Do not rely solely on visual and manual exploration of the peritoneal cavity and the retroperitoneum.

■ The initial necrosectomy offers the best possible exposure, and thus every attempt at a complete and safe necrosectomy should be pursued at this time.

■ Resist the urge to "debride" a possible "bridge" of tissue traversing the lesser sac cavity after blunt necrosectomy; this "bridge" most probably represents the middle colic vessels.

Percutaneous Necrosectomy

■ Use of a "level 1" fluid warmer provides pressurized warm fluid for intraoperative irrigation.

■ Be prepared to come back another day or two later rather than be overzealous with the initial or subsequent debridement.

■ Significant bleeding may be controlled by balloon tamponade, while laparotomy access and surgical control is obtained.

■ Discontinue the procedure if the patient shows signs of cardiovascular instability; resuscitate the patient, lavage the cavity, and come back another day.

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