Surgical treatment in patients with severe acute pancreatitis is still a controversial subject, ranging from sole conservative to an aggressive approach. This article gives an overview of the literature with regard to indications for surgery, timing and techniques of operative treatment concepts in severe acute pancreatitis with special attention to the recommended necrosectomy and closed continuous lavage of the involved retroperitoneum. Taking into account recent findings from microbiological data we developed a new algorithm in patients with acute pancreatitis. All patients with proven acute necrotizing pancreatitis receive an antibiotic therapy for 2 weeks beside the intensive care measures. So far only one third (33%) had infected pancreatic necrosis in the 3rd week of the onset of the disease and were managed surgically. The delay resulted in optimal surgical conditions for necrosectomy and a mortality rate of 0%. This new concept and therapeutic approach with the early suitable antibiotic therapy in patients with proven necrotizing pancreatitis is recommended to (1) decrease the infection rate and (2) delay surgical intervention to the 3rd week of the disease with optimal surgical conditions. It seems more and more likely that only patients with proven infected pancreatic necroses are candidates for surgical intervention.