This is the CT of a 43 year old male patiënt with infected necrotizing pancreatitis that will undergo a VARD procedure; Videoscopic Assisted Retroperitoneal Debridment. Two weeks before this procedur...

This is the CT of a 43 year old male patiënt with infected
necrotizing pancreatitis that will undergo a VARD procedure;
Videoscopic Assisted Retroperitoneal Debridment. Two weeks before
this procedure two large bore percutaneous drains were placed in the
peripancreatic collection. The patient i...s placed in supine
position with the left side 30 degrees elevated. A 5-7 cm subcostal
incision is made in the left flank. With help of CT images and by
following the percutaneous drain, the subcutaneous tissue and the
fascia are dissected and we enter the retroperitoneal peripancreatic
collection. First, with a regular suction device any pus encountered
is removed. Two long sympathectomy hooks are inserted in order to
keep in the incision open. We than insert the zero degree
laparoscope. The first necrosis encountered is removed under direct
sight with the use of long grasping forceps. Following the
percutaneous drain deeper into the cavity, parts of loosely adherent
necrotic material are removed. Gently pulling we remove the necrotic
tissue. The suction device is helpful in removing any fluid
obstructing the view. Complete necrosectomy is not the ultimate aim
of this procedure. Only loosely adherent pieces of necrosis are
removed thereby keeping the risk of tearing underlying blood vessels
to a minimum. In the rare case of extensive bleeding, the
retroperitoneal cavity can be easily packed, either awaiting the
bleeding to definitely stop or to act as a bridge to angiographic
coiling. This patient is now 6 weeks after onset of disease. We
always try to postpone surgical intervention, if possible up to 30
days. On the left side of the collection is the percutaneous drain.
In this patient the drain had worked well for 2 weeks. When the
patient deteriorated again it was decided to perform the VARD
procedure. Large pieces of necrotic pancreas can be removed with
VARD. This is a big advantage ov VARD over pure endosopic or
percutaneous techniques. When all the necrotic tissue is removed we
clean the cavity. Two drains are left in situ as a postoperative
lavage system. The VARD procedure is performed via a 6 cm incision,
which is closed and continuous postoperative lavage started
immediately.