HIIC

After the cytoreductive surgery is complete, the Tenckhoff catheter and closed suction drains are placed through the abdominal wall and made watertight with a purse string suture at the skin. Temperature probes are secured to the skin edge. Using a running monofilament suture, the skin edges are secured to the Thompson self-retaining retractor, and a plastic sheet is incorporated into these sutures to create an open space beneath (Thompson Surgical Instruments, Traverse City, MI). A slit in the plastic cover is made to allow the surgeon's double-gloved hand access to the abdomen and pelvis (Figure 7). During the 90 minutes of perfusion, all the anatomic structures within the peritoneal cavity are uniformly exposed to heat and to chemotherapy. The surgeon vigorously manipulates all viscera to keep adherence of peritoneal surfaces to a minimum. A roller pump forces the chemotherapy solution into the abdomen through the Tenckhoff catheter and pulls it out through the drains. A heat exchanger keeps the fluid being infused at 44-46^oC so that the intraperitoneal fluid is maintained at 42-43^oC. The circuit used for administration of heated intraoperative intraperitoneal chemotherapy is diagrammed in Figure 8. The smoke evacuator is used to pull air from beneath the plastic cover through activated charcoal, preventing any possible contamination of air in the operating room by chemotherapy aerosols.

The standardized orders for heated intraoperative intraperitoneal chemotherapy are given in Table 5.

After the intraoperative perfusion is complete, the abdomen is suctioned dry of fluid, reopened, and reconstructive surgery is performed. It should be emphasized that no anastomoses are constructed until after the intraoperative chemotherapy perfusion is complete.

Heated intraoperative intraperitoneal chemotherapy by the Coliseum Technique. Continuous manipulation of the viscera causes uniform distribution of heat and chemotherapy to all peritoneal surfaces.

TABLE 5

Standardized orders for hyperthermic intraoperative intraperitoneal chemotherapy

Mitomycin C Orders

For adenocarcinoma from appendiceal, colonic, rectal, gastric and pancreatic cancer;
add _____ mg mitomycin C to 2 liters of 1.5% peritoneal dialysis solution.
Dose of mitomycin C for males 12.5 mg/m², for females 10 mg/m².
Use a 33% dose reduction for heavy prior chemotherapy, marginal renal function,
age > 60, extensive intraoperative trauma to small bowel surfaces, or prior radiotherapy.
Send 1 liter of 1.5% peritoneal dialysis solution to test the perfusion circuit.
Send 1 liter of 1.5% peritoneal dialysis solution for immediate postoperative lavage.
Send the above to operating room at _____ o’clock.

Cisplatin plus Doxorubicin Orders

For sarcoma, ovarian cancer, and mesothelioma; add _____ mg cisplatin to 2 liters of 1.5% peritoneal dialysis solution. Dose of cisplatin is 50 mg/m².
Add _____ mg Doxorubicin to the same 2 liters of 1.5% peritoneal dialysis solution.
The dose of doxorubicin is 15 mg/m².
Use a 33% dose reduction for heavy prior chemotherapy, marginal renal function,
age > 60, extensive intraoperative trauma to small bowel surfaces, or prior radiotherapy.
Send 1 liter of 1.5% peritoneal dialysis solution to test the perfusion circuit.
Send 1 liter of 1.5% peritoneal dialysis solution for immediate postoperative lavage.
Send the above to operating room at o’clock.

Circuit for hyperthermic intraoperative intraperitoneal chemotherapy perfusion. All plastic tubes are positioned in a standardized fashion except for the Tenckhoff catheter, which is located in the area at greatest risk for recurrence.