Figure 34

Peritonectomy procedures - patient position. The patient is placed in the lithotomy position, with the back extended on the operating table. The peritonectomy procedures include:

1. Greater omentectomy and splenectomy

2. Left subdiaphragmatic peritonectomy

3. Right subdiaphragmatic peritonectomy

4. Lesser omentectomy and cholecystectomy with stripping of the omental bursa

5. Complete pelvic peritonectomy

6. Partial or complete gastrectomy

From Sugarbaker PH: Peritonectomy procedures. Annals of Surgery 221:2942, 1995.

Figure 34B

Peritonectomy procedures - greater omentectomy / splenectomy. The abdomen is open from xiphoid to pubis. Often times the xiphoid is excised using a rongeur. Abdominal exposure is achieved throughout with the use of a Thompson self-retaining retractor (Thompson Surgical Instruments, Inc., Traverse City, MI). The greater omentum is elevated and then separated from the transverse colon using electrosurgery. This dissection continues beneath the peritoneum that covers the transverse mesocolon, in order to expose the anterior surface of the pancreas. All the branches of the gastroepiploic vessels on the greater curative 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. The splenic artery and vein at the tail of the pancreas are ligated in continuity and proximally suture ligated. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT and Rubin JT: Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 251, 1997.

Figure 34C

Peritonectomy procedures - left upper quadrant peritonectomy. To begin the dissection, the peritoneum, which constitutes the edge of the abdominal incision, is stripped away from the left posterior rectus sheath. Using clamps, strong traction is achieved. Laser-mode electrosurgery is used to strip peritoneum and tumor from the muscular tissues of the left hemidiaphragm exposing this muscle, the left adrenal gland, the distal portion of the pancreas, and the cephalad one-half of Gerota's fascia. The splenic flexure is moved medially in order to fully exposure the left upper quadrant. The tissues are transected using laser-mode electrosurgery on pure cut, but all blood vessels are coagulated prior to their division. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 251, 1997.

Figure 34D

Peritonectomy procedures - left upper quadrant peritonectomy completed. When the left upper quadrant peritonectomy is completed, the stomach may be reflected medially, revealing numerous ligated branches of the gastroepiploic vessels. The left adrenal gland, body and tail of the pancreas, and left Gerota's fascia are clearly exposed, as is the anterior peritoneal surface of the transverse mesocolon. The surgeon must carefully avoid the major branches of the left gastric artery and coronary vein in order to preserve the remaining vascular supply to the stomach. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 252, 1997.

Figure 34E

Peritonectomy procedures - right upper quadrant peritonectomy. Peritoneum is stripped away from the right posterior rectus sheath to begin this peritonectomy. Clamps are placed on the specimen and strong traction elevates the hemidiaphragm into the operative field. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 252, 1997. 

Figure 34F

Peritonectomy procedures - right upper quadrant peritonectomy with stripping of tumor from the liver surface. Tumor on the anterior surface of the liver is electroevaporated until the liver parenchyma is visualized. With both blunt and electrosurgical dissection, tumor is dissected away from the liver surface including Glisson's capsule. Hemostasis is achieved as the dissection proceeds using generous electrocoagulation. Isolated patches of tumor on the liver surface are electroevaporated with the electrosurgical tip bent (hockey stick configuration). Tumor must be dissected from deep within the umbilical fissure of the liver. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 252, 1997. 

 Figure 34G

Peritonectomy procedures - completed right upper quadrant peritonectomy. After tumor is stripped from the undersurface of the right hemidiaphragm and from the surface of the liver, it must be removed from the right retrohepatic space. With medial displacement of the liver, one can visualize the completed right upper quadrant peritonectomy. The anterior branches of the phrenic artery and vein are visualized and have been preserved. Not infrequently, tumor will densely adhere to the tendinous mid-portion of the left or right hemidiaphragm. If this occurs, the fibrous tissue infiltrated by tumor must be resected. This requires an elliptical excision of a portion of the hemidiaphragm. This defect is not closed until the heated intraoperative intraperitoneal chemotherapy has been used to thoroughly lavage the pleural space as well as the peritoneal cavity. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MI, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 253, 1997.

Figure 34H

Peritonectomy procedures - lesser omentectomy and cholecystectomy. The gallbladder is removed in a routine fashion from its fundus towards the cystic artery and duct. Cancerous tissue is bluntly dissected from above the porta hepatis by dividing the adenomucinosis directly over the common duct. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 253, 1997.

 Figure 34I

Peritonectomy procedures - lesser omentectomy with stripping of the omental bursa. One begins this dissection by separating the gastrohepatic fissure from the liver. The anterior surface of the left caudate process is exposed. Great care is taken not to traumatize the blood vessels on the surface of the caudate process. Also, the left hepatic artery may arise from the left gastric artery and cross through the hepatogastric fissure. If this occurs, the vessel should be avoided. The caudate lobe of the liver is cleared, using laser-mode electrosurgery. It is elevated so that peritoneum overlying the vena cava can be stripped away from this structure. The floor of the omental bursa is dissected up by dividing the phrenoesophageal ligament, and stripping the crus of the right hemidiaphragm. The left gastric artery is spared by dissecting, using laser-mode electrosurgery on the anterior vagus nerve, sparing the arcade constructed from right and left gastric arteries. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT: Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 254, 1997.

Figure 34J

Peritonectomy procedures - complete pelvic peritonectomy with resection of the uterus and rectosigmoid colon. To initiate the pelvic dissection, the peritoneum is stripped from the posterior surface of the lower abdominal incision, exposing the rectus muscle and the deep epigastric vessels. The muscular surface of the bladder is stripped from tumor using laser-mode electrosurgery. The urachus must be divided, and is often the point of traction for the bladder. Both round ligaments are divided as they enter the internal inguinal ring, and the ovarian veins are divided likewise. The right and left ureters are identified and stripped clear of tumor. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 254, 1997.

Figure 34K

Peritonectomy procedures - hysterectomy and transection of the mid-rectum. Beneath the peritoneal reflection, one works in a centripetal fashion to free up all of the pelvic peritoneum. An extra peritoneal suture ligation of the uterine arteries occurs just above the ureter, and close to the base of the bladder. The bladder is moved off the vagina just below the cervix. High voltage electrosurgery is used to excise the vaginal cuff with minimal bleeding. Posteriorly, the cul-de-sac is removed intact with the specimen. The mid-portion of the rectum is skeletonized and secured with a stapler. From Sugarbaker PH: Visceral and parietal peritonectomy procedures. (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 254, 1997.

Figure 34L

Peritonectomy procedures - complete pelvic peritonectomy after dissection is finished. Centripetal surgery is used to move around the entire pelvic tumor. A stapler through the mid-rectum allows one to transect the rectum and remove the extensive tumor mass. A circular colorectal anastomosis is performed. The vagina is closed with absorbable sutures. From Sugarbaker PH: Visceral and parietal peritonectomy procedures (In) Lotze MT, Rubin JT. Regional Therapy of Advanced Cancer. Lippincott-Raven: Philadelphia p 255, 1997.

Figure 34M

Peritonectomy procedures - antrectomy or gastrectomy. The antrum of the stomach is a fixed portion of the gastrointestinal tract. Consequently, a thick layer of mucinous tumor often covers it. An antrectomy using stapling instruments completes the cytoreduction. In patients with advanced disease, a total gastrectomy may be necessary. From Sugarbaker PH: Peritonectomy procedures (In) Annals of Surgery 221:29-42, 1995.

Figure 34N

Tubes and drains required for intraperitoneal chemotherapy and postoperative maintenance. Chest tubes are placed in the pleural spaces if a subdiaphragmatic peritonectomy was performed. Closed suction drains are placed in the abdomen beneath the right and left hemidiaphragm. A third closed suction drain is placed in the pelvis. In many patients, a fourth closed suction drain is placed across the abdomen just beneath the abdominal incision. A curled Tenckhoff catheter is positioned in the lower abdomen. From Sugarbaker PH: Peritonectomy procedures (In) Annals of Surgery 221:2942, 1995. 

Figure 35

Laser-mode electrosurgery using a ball tip. The electrosurgical generator is placed on pure cut and at high voltage. The ball tip results in a lens shaped (lenticular) defect. This greatly facilitates exposure of the structure being dissected free. In contrast, a linear defect is created by the traditional spatula electrosurgical tip.