1. Open management of infected pancreatic necrosis – Inter Pulse Jet Irrigation and Modified Vacuum Mesh-Foil Laparostomy MutafchiyskiV Hepato-Biliary-Pancreatic and Transplant Surgery Military Medical Academy – Sofia, Bulgaria

2. Jet irrigation The efficacy in the treatment of contaminated wounds is well known It fulfills the three fundamental principles of surgical management of intra abdominal infection, also: Eliminate the source of sepsis Reduce the degree of contamination Prevents recurrent infection

4. Un vital structures

5. Foreign bodies

6. Bacterial contamination

7. Fibrin and Coagula

8. Vessels

9. Nerves

10. Muscle fibers

11. Spare vital parenchymaMadden J, Edlich R. Curr Top Surg Res 1971

12. Inter Pulse Jet Irrigation

13. Inter Pulse Jet Irrigation Considerable reduction of bacterial contaminationcompare with conventional techniques Missing data for its application in open abdominal surgery Well combination between the irrigation and the aspiration of the necrotic tissues Gold standard for wound treatment in USA

14. Temporary abdominal closure Surmounting of the abdominal compartment syndrome is the other crucial point in the management of severe pancreatitis It could be achieved by laparostomy with delay of abdominal closure We apply modified vacuum mesh foil laparostomy

15. Vacuum mesh foil laparostomy Self adhesive folio Abdominal wall Abdominal wall Silicone / nylon folio Mesh negative suction drains Gauzes

16. Conclusion Application of Inter pulse jet irrigation for necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis Although this technique is still evolving in open abdominal surgery, it is proven to be safe and efficient and should be evaluated against existing standards of treatment