Surgical step-up approach. Surgical step-up approach consisting of percutaneous catheter drainage (PCD) and video-assisted retroperitoneal débridement (VARD). (A) Cross-sectional image and torso depicting a peripancreatic collection. The preferred route is through the left retroperitoneal space between the kidney, spleen and descending colon. A percutaneous catheter drain is inserted in the collection to mitigate sepsis and postpone or even obviate necrosectomy. The area of detail is shown in (B). (C) A 5 cm subcostal incision is made and the percutaneous drain is followed into the collection. The first necrosis is removed under direct vision with a long grasping forceps, followed by further debridement under videoscopic assistance (D). (Reprinted from van Brunschot et al. ; copyright 2013, with permission from Elsevier).