The onlay patch can be omitted with low recurrence and complication rates if the posterior wall defects do not exceed the inner Posiflex(®) ring diameter.

Background Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal‐access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. Methods This retrospective, observational study documented patients who had undergone a step‐up MARPN between 1 January 2010 and 31 December 2016. A minimum follow‐up of 1 year was required for inclusion. The step‐up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. Results Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step‐up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1–7) and 1 (1–6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). Conclusion A step‐up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.