gpm cyto

Title Page | Introduction | Principles of Intraperitoneal Chemotherapy | Current Indications for Cytoreductive Surgery and Intraperitoneal Chemotherapy
Heated Intraoperative Intraperitoneal Chemotherapy by the Coliseum Technique
Immediate Postoperative Abdominal Lavage in Preparation for Early Postoperative Intraperitoneal 5-Fluorouracil
Early Postoperative Intraperitoneal Chemotherapy for Adenocarcinoma | Induction Intraperitoneal Chemotherapy for Debilitating Ascites
Cytoreductive Surgery for Peritoneal Surgacy Malignancy - Pertitonectomy Procedures | Results of Treatment of Peritoneal Surface Malignancy
Conclusions | References

VII.

CYTOREDUCTIVE SURGERY FOR PERITONEAL SURFACE MALIGNANCY
- PERITONECTOMY PROCEDURES

Not all six of these peritonectomy procedures will be required in all patients. The peritoneal surfaces are stripped of tumor only where there is visible disease. The surgeon's goal with the cytoreduction is to remove as much tumor as is possible (9). The smaller the cancer volume that remains for chemotherapy treatments, the better the results will be.

FIGURE 10

Position and incision for peritonectomy procedures. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995 (with permission).

Position and incision

The patient is placed in a supine position with the gluteal folds advanced to the break in the operating table in order to provide full access to the perineum during the surgical procedure (Figure 10). This modified lithotomy position is achieved with the legs extended in St. Mark's leg holders (AMSCO, Erie, PA). The weight of the legs must be directed to the bottom of the feet by positioning the footrests so that minimal weight is borne by the calf muscle.

All surfaces of the St. Mark's stirrups are protected by egg crate foam padding. The thighs and legs are surrounded by alternating pressure devices (SCB Compression Boots, Kendall Co., Boston, MA). These should be operative prior to the induction of anesthesia for maximal protection against venothrombosis. A hyperthermia blanket is placed over the chest. arms and head of the patient (Bair Hugger Upper Body Cover, Augustine Medical, Eden Prairie, MN), and also beneath the torso (Cincinnati Sub-Zero, Cincinnati, OH).

Abdominal skin preparation is from mid-chest to mid-thigh. The external genitalia are prepared in the male, and in the female, a vaginal preparation is also used. The Foley catheter is inserted after the skin preparation so that this catheter can be accessed during the surgical procedure. A large bore silastic nasogastric tube is placed within the stomach (Argyle Silastic Salem Sump Tube, Sherwood Medical, St. Louis, MO).

Abdominal exposure, greater omentectomy, and splenectomy

The abdomen is opened from xiphoid to pubis (Figure 11). The xiphoid is excised using a rongeur. Generous abdominal exposure is achieved through the use of a Thompson Self-Retaining Retractor (Thompson Surgical Instruments, Inc., Traverse City, Ml). The standard tool used to dissect tumor on peritone4 surfaces from the normal tissues is a ball-tip electrosurgical hand piece (Valleylab, Boulder, CO). The ball-tip hand piece is placed at the interface of tumor and normal tissues. The focal point for further dissection is placed on strong traction. The electrosurgical generator is used on pure cut at high voltage (Birtcher Electrosurgical, Englewood, CO). The 3mm ball-tip electrode is used for dissecting on visceral surfaces including stomach, small bowel, and colon. When more generalized tumor destruction is required, for example on the liver surface, the ball-tip will cause more rapid tumor destruction if used in the hockey stick configuration.

Using ball-tip electrosurgery on pure cut creates a large volume of plume because of the carbonization and electroevaporation of tissue. In order to maintain visualization of the operative field and to preserve a smoke-free atmosphere in the operating theater, a smoke filtration unit is utilized (Stackhouse, Inc., El Segundo, CA). The vacuum tip is maintained two to three inches from the field of dissection whenever electrosurgery is in use.

In order to free the mid-abdomen of a large volume of tumor, a complete greater omentectomy is performed. The greater omentum is elevated and then separated from the transverse colon using ball-tip electrosurgery. This dissection continues beneath the peritoneum that covers the transverse mesocolon, in order to expose the anterior surface of the pancreas. All branches of the gastroepiploic vessels on the greater curvature of the stomach are clamped, ligated, and divided. Also, the short gastric vessels are transected. With traction on the spleen, the anterior fascia of the pancreas is elevated from the gland Using ball-tip electrosurgery. This freely exposes the splenic artery and vein at the tail of the pancreas. These vessels are ligated in continuity and proximally suture ligated. The specimen of greater omentum and spleen is often free at this point for submission to pathology. In some patients, the left upper quadrant peritonectomy must be completed before the specimen is released.

FIGURE 11

Abdominal exposure, greater omentectomy, and splenectomy. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Left upper quadrant peritonectomy

In order to begin exposure of the left upper quadrant, the portion of the peritoneum, which constitutes the edge of the abdominal incision, is stripped away from the posterior rectus sheath (Figure 12). To secure this peritoneal layer, Kelly clamps are placed on it at 10 cm intervals. This allows traction to be achieved on the tumor specimen throughout the left upper quadrant.

The left upper quadrant peritonectomy involves the stripping of all tumor tissue from beneath the left hemidiaphragm to expose diaphragmatic muscle, left adrenal gland, distal portion of the pancreas, and the cephalad one-half of the perirenal fat. In order to achieve full exposure of the left upper quadrant, the splenic flexure is released from the left abdominal gutter and moved medially by dividing tissue along Toldt's line.

Stripping of tumor tissue from beneath the left hemidiaphragm is accomplished with ball-tip electrosurgery and not by blunt dissection. Numerous blood vessels between the diaphragm muscle and its peritoneal surface must be electrocoagulated before their transection or unnecessary bleeding will occur. Tissues are transected using ball-tip electrosurgery on pure cut, but all blood vessels are electrocoagulated prior to their division.

FIGURE 12

Peritoneal stripping from beneath the left hemidiaphragm. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Left upper quadrant peritonectomy completed

When the left upper quadrant peritonectomy is completed the stomach may be reflected medially. Numerous ligated branches of the gastroepiploic vessels are evident. The left adrenal gland, pancreas, and left Gerota's fascia are completely exposed, as is the anterior peritoneal surface of the transverse mesocolon. With all the upper abdominal peritonectomy procedures, the surgeon must carefully avoid the major branches of the left gastric artery and coronary vein in order to preserve the sole remaining vascular supply to the stomach (Figure 13).

FIGURE 13

Left upper quadrant peritonectomy completed. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Right upper quadrant peritonectomy

Peritoneum is stripped away from the right posterior rectus sheath to begin the peritonectomy in the right upper quadrant of the abdomen (Figure 14). Kelly clamps are placed on the specimen and strong traction is used to elevate the hemidiaphragm into the operative field. Again, ball-tip electrosurgery on pure cut is used to divide tissue planes. Coagulation current is used to seal blood vessels as they are encountered.

FIGURE 14

Peritoneal stripping from beneath the right hemidiaphragm. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Dissection beneath tumor through Glisson's capsule

The stripping of tumor from the muscular surface of the diaphragm continues until the bare area of the liver is encountered (Figure 15). At this point, tumor on the anterior surface of the liver is electroevaporated until the liver surface is visualized. With electrosurgical dissection, one lifts tumor off the dome of the liver moving through or beneath Glisson's capsule. Hemostasis is achieved as the dissection proceeds using generous coagulation electrosurgery and the argon beam electrocoagulation (Birtcher Electrosurgical, Englewood, CO). Isolated patches of tumor on the liver surface are electroevaporated with the distal 2 cm of the ball-tip bent and stripped of insulation (hockey stick configuration). Ball-tip electrosurgery is also utilized to extirpate tumor in and around the umbilical fissure of the liver.

FIGURE 15

Dissection beneath tumor through Glisson's capsule. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Removal of tumor from beneath the right hemidiaphragm, from right subhepatic space, and from the surface of the liver

Tumor from beneath the right hemidiaphragm, from the right subhepatic space, and from the surface of the liver forms an envelope as it is removed en-bloc (Figure 16). The dissection is greatly simplified if the tumor specimen can be maintained intact. The dissection continues laterally on the right to encounter the perirenal fat covering the right kidney. Also, the right adrenal gland is visualized as tumor is stripped out of Morrison's pouch (right sub hepatic space). Care is taken not to traumatize the vena cava or to disrupt caudate lobe veins that pass between the vena cava and segment 1 of the liver.

FIGURE 16

Removal of tumor from beneath the right hemidiaphragm, from right subhepatic space, and from the surface of the liver. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Completed right upper quadrant peritonectomy

With strong traction on the right costal margin and medial displacement of the liver, one can visualize the completed right upper quadrant peritonectomy. The anterior branch of the phrenic artery and vein are seen and have been preserved (Figure 17). The right hepatic vein and the vena cava below have been exposed. The right adrenal gland and Gerota's fascia covering the right kidney constitutes the base of the dissection. Not infrequently, tumor will be densely adherent to the tendinous mid-portion of the left or right hemidiaphragm. If this occurs, the fibrous tissue infiltrated by tumor must be resected. This usually requires a generous elliptical excision of a portion of the hemidiaphragm. The defect in the diaphragm is left open until the intraperitoneal chemotherapy is complete. Then it is closed with interrupted sutures and rarely causes respiratory problems postoperatively. Implantation Of tumor cells into the pleural space must be avoided by treating the pleural space along with the peritoneal cavity with heated intraoperative intraperitoneal chemotherapy.

FIGURE 17

Completed right upper quadrant peritonectomy. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42 1995.

Lesser omentectomy and cholecystectomy

The gall bladder is removed in a routine fashion from its fundus towards the cystic artery and cystic duct (Figure 18). These structures are ligated and divided. The tissue superior to the porta hepatis is usually heavily covered by tumor. Using strong traction, the cancerous tissue, which covers the common duct and hepatic artery, is fractured away from the gall bladder bed towards the duodenum. In this dissection ball-tip electrosurgery may be excessively traumatic; structures of the porta hepatis are dissected free of tumor by the spreading of a clamp. Electrocoagulation is used to divide tissues above the clamp.

To begin resection of the lesser omentum, one dissects along the gastrohepatic fissure that divides liver segments 2 and 3 from segment 1. One goes back to ball-tip electrosurgery for this maneuver and for electroevaporation of the tumor from the anterior surface of the left caudate process. Great care is taken not to traumatize the caudate process, for this can result in excessive and needless blood loss.

The segmental blood supply to the caudate lobe is located on the anterior surface of this segment of the liver, and hemorrhage may occur with only superficial trauma. Also, one must be aware that the left hepatic artery may arise from the left gastric artery and cross through the hepatogastric fissure. If this occurs, one dissects with a spreading clamp along this vessel to isolate and preserve it.

FIGURE 18

Lesser omentectomy and cholecystectomy. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221.29-42, 1995.

Stripping of the omental bursa

As one clears the left part of the caudate liver segment of tumor, the vena cava is visualized directly beneath (Figure 19). To strip the omental bursa, strong traction is maintained on the tumor and ball-tip electrosurgery is used to divide the fibrous tissue above the vena cava and clear the peritoneum that lies anterior to the crus of the right hemidiaphragm.

FIGURE 19

Stripping of the omental bursa. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221.29-42, 1995.

The common hepatic artery and the origin of the left gastric artery are skeletonized and avoided. A spreading clamp with blade electrosurgery is used to visually identify the cephalad and caudad branching of the left gastric artery and the coronary vein. Dissection of lesser omental fat, using pressure between the thumb and index finger will help identify the two major branches of the left gastric artery. They are preserved in order to ensure adequate blood supply to the stomach. Several branches of the left gastric artery must remain intact in order to provide blood supply to the stomach.

The surgeon continues to dissect in a clockwise direction along the lesser curvature of the stomach. Care is taken to preserve as much lesser omental fat as is possible, only removing tumor tissue. The branches of the anterior vagus nerve to the antrum of the stomach are preserved if possible. Finally, dissection using a spreading clamp around celiac lymph nodes allows the specimen to be released. If the pylorus is firm and tight, a pyloroplasty must be performed in order to allow the stomach to empty. If the pylorus is widely open, a gastric drainage procedure will not be needed even though a vagotomy has been performed.

Pelvic peritonectomy with resection of the rectosigmoid colon

To initiate the pelvic dissection, the peritoneum is stripped from the posterior surface of the lower abdominal incision, exposing the rectus muscle (Figure 20). The muscular surface of the bladder is seen as ball-tip electrosurgery strips tumor-bearing peritoneum and pre-peritoneal fat from this structure. The urachus must be divided and used as a point for traction for this dissection. Round ligaments are divided as they enter the internal inguinal ring on both the right and left in- the female patient.

The peritoneal incision around the pelvis is completed by stripping peritoneum posteriorly up to the duodenum and the Treitz ligament. Right and left ureters are identified and preserved. In females, the right and left ovarian veins are ligated and divided at the lower pole of the kidney. A linear stapler is used to divide the colon at the junction of sigmoid and descending colon. The vascular supply of the distal portion of the bowel is traced back to its origin on the aorta. The inferior mesenteric artery is ligated and divided. This allows one to pack all of the viscera, including the proximal sigmoid colon, into the upper abdomen.

FIGURE 20

Pelvic peritonectomy. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

Hysterectomy and transection of the rectum beneath the peritoneal reflection

Ball-tip electorsurgery is used to dissect deep to the mesorectum (Figure 21). One works in a centripetal fashion to free up the entire pelvis. An extraperitoneal suture ligation of the uterine arteries occurs just above the ureter and close to the base of the bladder. In females, the bladder is gently moved off from the cervix and the vagina is entered. The vaginal cuff anterior and posterior to the cervix is divided using ball-tip electrosurgery and the perirectal fat inferior to the posterior vaginal wall is encountered. Ball-tip electrosurgery is used to divide the perirectal fat beneath the peritoneal reflection. This ensures that all tumor which occupies the cul-de-sac is removed intact with the specimen. The mid-portion of the rectal musculature is skeletonized using ball-tip electrosurgery. A roticulator stapler (Autosuture Inc., Norwalk, CT) is used to close the rectal stump.

Vaginal closure and colorectal anastomosis

Interrupted absorbable sutures are used to close the vaginal cuff and prevent leakage of fluid during intraperitoneal perfusion (Figure 22). A monofilament suture in a purse string fashion is used to secure the stapler anvil in the proximal sigmoid colon. A circular stapling device is passed into the rectum and the trochar used to penetrate the middle of the rectal staple line. The body of the circular stapler and anvil are mated and the stapler fired to complete the low colorectal anastomosis (Intraluminal Stapler ILS-33, Ethicon, Cincinnati, OH). This anastomosis is performed after the heated intraoperative intraperitoneal chemotherapy is completed.

FIGURE 21

Resection of rectosigmoid colon beneath the peritoneal reflection. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

FIGURE 22

Complete pelvic stripping and rectosigmoid resection. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

An absolute requirement of a complication-free, low colorectal anastomosis is an absence of tension on the suture line. Adequate mobilization of the entire left colon with preservation of its blood supply is necessary. To accomplish this requires several steps.

The branches of the inferior mesenteric artery (superior hemorrhoidal, sigmoid and left colic) are ligated as they arise from this vascular trunk. This converts the Y-configuration of these vessels to a V-configuration. This allows for great stretching of the left colic mesentery with a preservation of adequate blood supply to the distal colon (Figure 23). Then the inferior mesenteric artery is ligated and then suture ligated on the aorta. The inferior mesenteric vein is divided as it courses around the duodenum. The mesentery of the' transverse colon and splenic flexure are completely elevated from the perirenal fat. Taking care to avoid the left ureter, one divides the left colon mesentery from all of its retroperitoneal attachments. These maneuvers will allow the junction of sigmoid and descending colon to reach to the low rectum for a tension-free anastomosis.

In order to ensure a safe colorectal anastomosis, one examines the proximal and distal tissue rings for their completeness. One insufflates air under pressure into the rectum with a water-filled pelvis to check for staple closure and an air-tight anastomosis: One observes that the distal colonic segment follows the concavity of the sacrum showing that there is no tension on the stapled anastomosis. A rectal examination is performed to check for staple-line bleeding at the anastomosis.

FIGURE 23

Preservation of the intermediate vasculature to the distal colon by converting the Y-configuration of the sigmoidal vessels to a V-configuration.

Antrectomy and gastric reconstruction

The gastric antrum, as with other motionless intraabdominal structures, may be so densely surrounded by tumor that resection rather than peritoneal stripping is required for complete tumor removal. The right gastric artery is divided and blunt dissection used to separate the first portion of the duodenum from the pancreas. A stapler (Ethicon TLC-75. Cincinnati, OH) is used to close off and transect the duodenum just below the last visible evidence of tumor. Similarly, a stapler (Ethicon TA 90, Cincinnati, OH) divides the stomach proximally.

The duodenal and gastric staple lines are inverted with interrupted sutures and a side-to-side gastrojejunostomy is performed (Figure 24). These suture lines and the inversion of staple lines are not performed until the heated intraoperative intraperitoneal chemotherapy is completed.

FIGURE 24

Gastric reconstruction after antrectomy.

Total gastrectomy and reconstruction

In some patients, a total gastrectomy will be needed to clear the left upper quadrant of mucinous tumor. In most instances, this indicates that the tumor is a more aggressive type, usually called pseudomyxoma/carcinoma hybrid. Alternatively, the patient may have had many prior surgical procedures with prior extensive dissection in the left upper quadrant.

To perform the gastrectomy, the esophagus is closed with a linear stapler (Ethicon TA-30, Cincinnati, OH) and then transected. The duodenum is transected just distal to the pylorus with a linear stapler. The left gastric artery and vein are ligated and suture ligated. Final attachments of the stomach to celiac lymph nodes and to the superior portion of the head of the pancreas are divided using ball-tipped electrosurgery. Great care is taken not to traumatize the anterior surface of the pancreas.

To reconstruct the gastrointestinal tract after gastrectomy that is part of a complete cytoreduction, a duodenal exclusion operation is performed. This protects the esophagojejunal anastomosis. Approximately 20 cm below the ligament of Treitz a portion of jejunum is transected with a linear stapler and brought in a retrocolic fashion up to the esophagus. The esophageal staple line is removed and a purse-string suture is used to secure the anvil of a circular stapler in the distal esophagus (Ethicon ILS-29, Cincinnati, OH). The staple line closing the proximal jejunum is removed and the stapler is passed approximately 5 cm into the jejunum and then the spear is passed through the jejunal wall. It is mated with the anvil within the esophagus, and the staple line is completed. The proximal jejunum is stapled off, and then the staple line inverted with interrupted sutures. All of these suture lines are performed after the heated intraoperative intraperitoneal chemotherapy has been completed.

The portion of jejunum proximal to the linear staple line is now brought out in the left upper quadrant as an end ostomy in order to divert all bile and digestive enzymes from the gastrointestinal tract. This diverting jejunostomy is closed between 3 and 6 months postoperatively as part of a second-look procedure (Figure 25).

FIGURE 25

In patients who require gastrectomy in addition to extensive cytoreduction, a high diverting jejunostomy is performed. This ostomy is closed in approximately six months with a second-look surgery.

Tubes and drains required for heated intraoperative and early postoperative intraperitoneal chemotherapy

Closed suction drains are placed in the dependant portion of the abdomen. This includes the right subhepatic space, the left subdiaphragmatic space and the pelvis.

FIGURE 26

Tubes and drains required for heated intraoperative and early postoperative intraperitoneal chemotherapy. From Sugarbaker PH: Peritonectomy procedures. Ann Surg 221:29-42, 1995.

A Tenckhoff catheter (Quinton Curled Peritoneal Catheter, Quinton, Inc., Seattle, WA) is placed through the abdominal wall in order to administer heated intraoperative intraperitoneal chemotherapy (Figure 26). All transabdominal drains and tubes are secured in a watertight fashion with a purse string suture at the skin. Right angle thoracostomy tubes (Deknatel, Floral Park, NY) are inserted on both the right and left side in order to prevent fluid accumulation in the chest as a result of intraperitoneal chemotherapy and diaphragm stripping.

As soon as the abdomen is closed, irrigation of the abdomen with 1.5% dextrose peritoneal dialysis solution (Abbott Laboratories, Chicago, IL) is begun. Standardized orders for early postoperative intraperitoneal lavage and for perioperative intraperitoneal chemotherapy administration are instituted (Tables 6 and 7).