History and Preoperative Assessment: The patient is a 67-year-old female who was hospitalized with severe acute gallstone pancreatitis. Five weeks later, she was readmitted with abdominal pain, nausea, vomiting, and weight loss. On imaging, she was found to have a large complex fluid collection consistent with walled off pancreatic necrosis (WOPN).
Operative Technique: The abdomen was entered laparoscopically and the robot was docked. A linear anterior gastrotomy was created. Intraoperative ultrasound was performed along the posterior gastric wall to identify the WOPN. A posterior gastrotomy was created to access the collection, where a large amount of purulent and solid necrotic debris was encountered. A cystogastrostomy was created using a 60 mm, 2.5 mm linear stapler. A pancreatic necrosectomy was performed through the cystogastrostomy using irrigation, suction, and manual debridement. The wall of the posterior gastrostomy was oversewn with 2-0 absorbable suture in a running locking fashion. The anterior gastrotomy was closed primarily using 3-0 barbed absorbable suture. A robotic assisted cholecystectomy was performed in the standard fashion. Finally, an upper endoscopy was performed which revealed an intact anterior gastrotomy closure as well as a hemostatic, patent cystogastrostomy.
Postoperative Care and Follow-up: The patient was discharged on postoperative day 2 after adequate pain control and full diet tolerance. She had complete resolution of her symptoms with steady weight gain at her 2 week follow-up evaluation. An interval CT scan at 6 weeks demonstrated near complete resolution of the WOPN.