MINIMAL ACCESS RETROPERITONEAL NECROSECTOMY IN STEP UP APPROACH
Rajesh Gupta*1, Mohanasundaram Avudaiappan1, Aditya V. Kulkarni1, Venu B. Mulpuri2, Dinesh K. Bhuria1, Surinder S. Rana1, Mandeep Kang1
1Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India; 2ESI Hospital Sanath Nagar, Hyderabad, Andhra Pradesh, India
Introduction
Acute pancreatitis is complicated by pancreatic and peripancreatic necrosis in 15-20% of patients. Around 30% are associated with infected pancreatic necrosis (IPN). The conventional open necrosectomy is associated with high mortality and morbidity. Step-up approach is preferred as the standard of care for infected pancreatic necrosis (IPN).Retroperitoneal approach is mostly effective to drain the collection and necrotic material. This approach does not require a large abdominal incision and reportedly has better outcomes. We have used Minimal incision retroperitoneal necrosectomy(MIRN) as part of the step-up approach. The primary aim of this study was to see how minimal incision necrosectomy was incorporated in the minimal access approach compared to conventional open necrosectomy in terms of surgical outcomes. Methods: Present study is single-center retrospective study of prospectively maintained database from April 2008 to December 2021. Retroperitoneal necrosectomy was performed for 1) predominant necrotic collection in the body and tail region and 2) when the necrotic cavity was close to the abdominal wall. We first placed the PCD in the necrotic collection as step up approach choosing short straight route avoiding bowel. The procedure of VARD is standard and already described. Minimal incision retroperitoneal necrosectomy included 4- 5cms incision on either side of pigtail depending on location of collection. The incision was deepened till posterior rectus sheath by cutting muscle fibres and then PCD opening in the posterior rectus sheath was enlarged with the instrument or digitally. The necrotic cavity was accessed and digital necrosectomy was performed using deep retractors and the necrosum removed with ring forceps using gentle traction. Large bore foley catheters were placed in the cavity for irrigation and drainage. Results: 122 patients were included in the study. Seventy-eight patients in the open necrosectomy group and 44 in the minimal incision group. Both the groups are comparable in demographic variables {median age 37 vs. 35.5, female 16.6 % vs. 20.4%} in open and MIRN, respectively. The most common etiology was alcohol in both groups (56.4 % open vs. 45.5 % MIRN). APACHE II at presentation was 10.81 ± 4.34 open vs. 11.07 ± 3.75 MIRN, p=0.73. Incidences of multi-organ failure was comparable in two groups, p=0.216. Modified CTSI was 8.79 ± 1.8 in open vs. 9.14 ± 1.25 in MIRN, p=0.268. Postoperative mortality was significantly high in the open necrosectomy group, 35.8% vs. 20.5%, p=0.075. The postoperative stay was also significantly higher in the open group, 23.62 ± 16.61 vs. 11.77 ± 7.73, p= 0.0. Conclusion: Minimal incision necrosectomy was associated with lesser mortality and morbidity than conventional open necrosectomy with proper patient selection.
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