Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in the Management of Peritoneal Carcinomatosis

Rahul Rajeev, MBBS; Kiran K. Turaga, MD

Disclosures

Cancer Control. 2016;23(1):36-46. 

In This Article

Techniques of Peritonectomy

The oncological principles of peritonectomy surgeries were first described by Sugarbaker.[12] The outcome of cytoreductive surgery is reliant on the extent of the removal of tumor deposits from visceral and parietal peritoneal surfaces, and surgical techniques vary depending on the site and volume of disease. Peritoneal staging is performed using well-established scoring systems (Peritoneal Cancer Index [PCI], Simplified PCI) that utilize tumor size and region of distribution to quantify disease burden. Techniques of peritonectomy require complete knowledge of embryology and anatomy to ensure successful extirpation of tumor.

Greater Omentectomy

The greater omentum is elevated off the transverse mesocolon by stripping the entire surface of the mesocolon. The dissection includes separation of the specimen from the gastroepiploic vessels (potential ligation) and division of the short gastric vessels. The omentum is elevated off the splenic hilum (splenectomy if necessary) and the anterior surface of the pancreas. Meticulous dissection of the omentum is essential for complete tumor removal.

Epigastric Peritonectomy

The falciform ligament is separated from the umbilicus along with the anterior peritoneum and resected flush with the liver surface to include the ligamentum teres hepatis. The bridge of liver is often divided to access the left portal vein.

Right Hemidiaphragmatic Peritonectomy

Diaphragmatic muscle is stripped along its entirety after making a cruciate incision in the anterior peritoneum. The peritonectomy includes stripping the Gerota fascia, the right adrenal gland, and the Glisson capsule of the liver. Complete mobilization of the liver is essential and the retrohepatic inferior vena cava (IVC) is used as the medial border of the dissection.

Left Hemidiaphragmatic Peritonectomy

The upper left portion of the cruciate incision is used to initiate the left hemidiaphragmatic peritonectomy. Complete stripping of the diaphragmatic fibers with skeletonization (or ligation) of the phrenic vessels is undertaken. Dissection includes stripping the adrenal gland and Gerota fascia.

Lesser Omentum Peritonectomy

The hepatoduodenal ligament and the pars flaccida are dissected from the caudate lobe of the liver and the porta hepatis. Careful dissection of the celiac axis branches and the right gastric arteries can elevate the tumor off of the lesser omentum. The IVC bursa is occasionally stripped, using the IVC, caudate lobe of the liver, and the left limb of the right crus as anatomical landmarks.

Pelvic Peritonectomy

Pelvic peritonectomy includes resection of the anterior peritoneum with the urachus and the medial umbilical ligaments. Skeletonization of the ureters, gonadal vessels, and resection of the upper rectum are often necessary to complete the peritonectomy. Visceral resections of the uterus and ovaries are performed as necessary.

Anterior Peritonectomy

Scar excision and resection of the anterior peritoneum is carefully undertaken with preservation of the rectus fascia at the initiation of the procedure. This becomes contiguous with the right hemidiaphragmatic peritonectomy performed in the right upper quadrant, the epigastric peritonectomy superiorly performed, the left hemidiaphragmatic peritonectomy performed in the left upper quadrant, the paracolic gutter peritonectomy laterally performed, and the pelvic peritonectomy inferiorly performed.

The completeness of cytoreduction is graded as CC-0 (no visible disease), CC-1 (< 2.5 mm residual disease), CC-2 (2.5–25 mm), and CC-3 (> 25 mm residual disease), or using the R score (R0 = complete resection, R1 = no gross disease with microscopic positive margins, R2 = macroscopic residual disease [R2a = < 5 mm, R2b = 6–20 mm, R2c = > 20 mm]).

processing....