Video-assisted retroperitoneal debridement for infected retroperitoneal fat necrosis following laparoscopic distal pancreatectomy.

Abstract

Video-assisted retroperitoneal debridement (VARD) is an established and minimally invasive treatment option for infected necrotizing pancreatitis. However, its application in the postoperative setting after pancreatic resection has rarely been described. We report a case of extensive infected retroperitoneal fat necrosis following laparoscopic distal pancreatectomy that was successfully managed using a step-up approach incorporating VARD. An 81-year-old woman underwent laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma of the pancreatic tail. On postoperative day (POD) 7, she developed sudden-onset abdominal pain. Computed tomography (CT) demonstrated enlargement of the remnant pancreas with increased peripancreatic fat stranding. Follow-up CT on POD 9 and 12 revealed progressive enlargement of the fluid collection around the pancreatic stump with rapid extension of inflammatory changes into the retroperitoneal space. Conservative management with fasting and antibiotic therapy resulted in temporary improvement in inflammatory markers. However, extensive infected retroperitoneal fat necrosis developed on POD 38. On POD 43, CT-guided percutaneous catheter drainage failed to achieve adequate source control due to highly viscous necrotic debris, necessitating surgical necrosectomy. An additional drainage tube was placed to establish a retroperitoneal access route, after which VARD was performed on POD 55, with removal of 61 g of necrotic fatty tissue. Inflammatory markers rapidly improved, and the patient was discharged in good condition on POD 102. Infected retroperitoneal fat necrosis after laparoscopic distal pancreatectomy was successfully managed using a step-up strategy incorporating VARD. This case highlights VARD as a minimally invasive therapeutic option for postoperative infected retroperitoneal fat necrosis.