Combined Laparoscopic and Choledochoscopic Necrosectomy for Infected Pancreatic Necrosis: A Case Report.

Infected pancreatic necrosis often necessitates intervention when initial step-up management fails. We present the case of a 63-year-old female with severe acute necrotizing pancreatitis complicated by extensive, multiloculated infected collections that persisted despite prolonged percutaneous catheter drainage and antibiotic therapy. Imaging demonstrated necrosis involving both the pancreatic head and tail regions, a distribution that limited the effectiveness of unilateral retroperitoneal or purely endoscopic approaches. Given the failure of drainage and the complex anatomical extent of disease, a combined laparoscopic and choledochoscopic necrosectomy was performed to achieve comprehensive debridement within a single procedure. Laparoscopy provided panoramic access to the lesser sac and retroperitoneum, enabling adhesiolysis and controlled entry into the necrotic cavities, while the flexible choledochoscope facilitated targeted irrigation and removal of debris within deep and anatomically complex regions, particularly in the pancreatic head. Double-lumen irrigation drains were placed to support postoperative lavage and cavity management. The procedure was completed without conversion to open surgery, with an operative time of 7 h and 11 min and an estimated blood loss of 800 mL. Postoperatively, the patient recovered with normalization of inflammatory markers and was discharged on postoperative day 50. Follow-up imaging demonstrated marked resolution of the necrotic collections, and no additional invasive interventions were required. This case illustrates that a combined laparoscopic and choledochoscopic approach may represent a feasible minimally invasive option for complex, pan-pancreatic necrosis refractory to drainage.