Indian J Surg Oncol (June 2016) 7(2):139–151

DOI 10.1007/s13193-016-0505-5

REVIEW ARTICLE

Cytoreductive Surgery and Peritonectomy Procedures

Sanket S. Mehta 1 & Aditi Bhatt 2 & Olivier Glehen 3,4

Received: 20 January 2016 / Accepted: 28 January 2016 / Published online: 3 February 2016
# Indian Association of Surgical Oncology 2016

Abstract Cytoreductive surgery (CRS) and hyperthermic is difficult to implement and careful patient selection is needed
intraperitoneal chemotherapy (HIPEC) has become widely for obtaining good results. Cytoreductive surgery is performed
accepted as an effective method of treating peritoneal metas- with the goal of complete removal of all macroscopic disease.
tases (PM) from various cancers. CRS performed with the This is achieved by peritonectomy procedures and en-bloc
goal of removing all the macroscopic disease and comprises resection of the viscera where required. Their use depends
of peritonectomy procedures and visceral resections. CRS is a on the extent of PM. Normal peritoneum is not excised, only
technically challenging surgery that requires a considerable that which is affected is removed [2].
amount of skill and appropriate patient selection. This article
is a review of the techniques and current recommendations for Patterns of Peritoneal Cancer Spread
performing CRS.
An understanding of the mechanisms and patterns of perito-
Keywords Cytoreductive surgery . Peritonectomy . neal cancer spread is required for treating PM. The peritoneum
Techniques of cytoreductive surgery . Pelvic peritonectomy . is a complex organ comprising of the parietal peritoneum lin-
Subphrenic peritonectomy . Multi-organ resection ing the abdominal wall and the visceral peritoneum covering
the abdominal and pelvic organs. It reflects and folds as it
covers the visceral organs, forming potential spaces between
its lining along the abdominal and pelvic walls. Additionally,
Introduction the ligaments, mesenteries and omentum are also formed from
its reflections over the abdominal and pelvic viscera. [3].
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal The network of reflections, folds, boundaries and potential
chemotherapy (HIPEC) has become widely accepted as an spaces provides a pathway for disease spread within the peri-
effective method of treating peritoneal metastases (PM) from toneal cavity and between the peritoneal and retroperitoneal
various cancers. [1] However this is a complex treatment that spaces. [4] Primary tumors arising from the peritoneum are
rare and cancer spread to the peritoneum, PM is caused by a
primary tumor arising elsewhere. [5] There are four pathways
* Olivier Glehen
of peritoneal cancer spread. [6]
olivier.glehen@chu-lyon.fr

1. Direct spread First, contiguous spread of tumor from one

1
Division of Peritoneal Surface Oncology, Saifee Hospital, organ to another can occur directly via the serosa. Tumors
MK marg, Charni road, Girgaon, Mumbai 400004, India of the stomach, colon and pancreas spread in that manner
2
Fortis Hospitals Limited, 154/9, Bannerghatta Road, Opp. IIM-B, to contiguous and non-contiguous organs. [7]
Bangalore 560076, India 2. Lymphatic spread: Tumor can also spread directly from one
3
Department of Surgical Oncology, Centre Hospitalier Lyon Sud, noncontiguous organ to another through the subperitoneal
Hospices Civils de Lyon, 69495 Pierre Bénite, France lymphatics along the ligaments, mesenteries and omenta.
4
Université Lyon 1, EMR 3738, 69600 Oullins, France This pattern of spread accounts for a small percentage of
140 Indian J Surg Oncol (June 2016) 7(2):139–151

PM and is seen is lymphomas especially non-Hodgkins necessitate a distal or total gastrectomy to achieve a com-
lymphomas. [8] plete cytoreduction. Layering of cancer on a peritoneal
3. Along the flow of ascitic fluid (Redistribution phenomenon) surface and a portion of the intestine may require en-
This is characteristic of pseudomyxoma peritonei and bloc peritonectomy and bowel resection to facilitate faster
ovarian cancer [9, 10]. The tumor cells follow the and complete removal [16].
movement of intraperitoneal fluid. Gravity causes the
fluid to collect in the pelvis. The negative pressure cre- Patient Selection for CRS and HIPEC
ated by respiratory movement causes an upward move-
ment of the fluid along the paracolic gutter to the The greatest criticism of CRS and HIPEC has been the mor-
subdiaphragmatic area from where it is redistributed bidity and mortality. Not all patients benefit from extensive
via the falciform ligament to the lesser and greater CRS [17]. Rapid recurrence of peritoneal metastases with or
omenta and over the bowel surfaces. The commonest without lymph node or systemic metastases occurs in patients
sites of PM are the pelvis, the lower end of the small bowel with extensive disease leading to morbidity without benefit in
mesentry, the right paracolic gutter, the undersuface of the survival. Quantitative prognostic indicators have been defined
diaphragm and the greater and lesser omenta. Besides, PM to measure the outcomes of CRS and HIPEC and these should
tend to involve the visceral peritoneum in greater volumes be used in selecting patients for the procedure. [18] These
at 3 definite sites, where the bowel is anchored to the indicators are histopathology, imaging findings, peritoneal
retroperitoneum. These are the rectosigmoid colon where cancer index (PCI) and the completeness of cytoreduction
it emerges from the pelvis (this site is also dependent score (CCR). [18, 19] Apart from the general health and
and tends to be more often heavily involved), the region fitness for the procedure, these indicators should be taken
of the ileocaecal valve and the region of the pylorus. into consideration before taking up a patient for surgery.
Small bowel sparing is characteristic and is due to the All patients need evaluation by a multidisciplinary team
constant peristaltic activity comprising of surgeon, medical oncologist, anesthesiolo-
4. Hematogenous route: This route is employed by both gist, intensivist, radiologist and pathologist.
intra and extra- abdominal tumors and PM arising
from breast cancer, lung cancer and melanoma spread Histopathology
by this route. [11]
In appendiceal tumors and pseudomyxoma peritonei, the
grade of the tumor has an impact on the outcome regardless
Basic Principles of the completeness of cytoreduction. [19] Low grade tumors
do better than high grade tumors and signet ring cell tumors.
CRS comprises of peritonectomy procedures and visceral [20] Patients with extensive disease also benefit from the com-
resections. The goal is to remove all macroscopic disease bined modality treatment. The same is not seen in other GI
leaving no residual disease or for some pathologies like cancers like colorectal cancer and gastric cancer where the
pseudomyxoma peritonei or peritoneal mesothelioma, disease histologic subtype has a lesser impact on survival [21]. In
that is not greater than 2.5 mm in size. The rationale being that peritoneal mesotheliomas, histopathology has a strong impact
intraperitoneal chemotherapy is not effective in eradicating on survival results and the epitheloid subtype do better than
tumor nodules larger than 2.5 mm in size. [12] CRS aims the biphasic or sarcomatoid sub-type [22].
at removal of macroscopic disease while HIPEC acts on
the microscopic disease. The various peritonectomy proce- Imaging
dures required to achieve complete tumor removal are listed
in Table 1 [13]. A contrast enhanced CT scan of the thorax abdomen and
Complete tumor removal may necessitate removal of adja- pelvis is the standard investigation used for evaluating
cent viscera. For example, a complete pelvic peritonectomy patients prior to surgery. It rules out major distant metas-
usually requires stripping of the pelvic side-walls, the perito- tases and may predict the extent of disease [23, 24]. The
neum overlying the urinary bladder, the cul-de-sac and resec- sensitivity of helical CT for peritoneal tumors less than
tion of the rectosigmoid with or without a panhysterectomy 1 cm was found to be only 25–50 % compared with
[14]. Metastases in the region of the ileocaecal valve may 85–95 % for larger tumor deposits [25]. In a multi-
necessitate a removal of the terminal ileum and limited part institutional study, Esquivel et al. found that the preoper-
of the right colon to achieve a complete resection. Disease ative CT PCI score underestimated the extent of carcino-
in the subpyloric space is often confluent with the tumor matosis in 33 % of patients [26]. In recent studies MRI
coming in from the foramen of Winslow and sometimes has been reported to be more accurate for detecting <1 cm
the tumor involving the lesser omentum. [15] This may nodules by some authors, while others have found no
Indian J Surg Oncol (June 2016) 7(2):139–151 141

Table 1 Peritonectomy
procedures and resections that are Peritonectomy procedures Resections
combined to achieve a complete
cytoreduction (reproduced from Anterior parietal peritonectomy Old abdominal incisions, umbilicus, epigastric fat pad
Ref 13 with permission) Left upper quadrant peritonectomy Greater omentum and spleen
Right upper quadrant peritnectomy Glissons capsule deposits
Pelvic peritonectomy Uterus, ovaries and rectosigmoid colon
Omental bursectomy Gall bladder and lesser omentum

difference [27, 28]. MRI results are also dependent on the (LS) score is determined. The LS score grades lesions as
expertise of the interpreter [28]. PET or PET-CT scans LS-0 score when no malignant deposits are visualised. LS-1
may add some more information in this direction by de- score signifies tumor nodules <0.5 cm; LS-2 score indicates
tecting extraabdominal (mediastinal or supraclavicular) tumour nodules between 0.5 to 5.0 cm; and an LS-3 score
lymphadenopathy. However, regarding evaluation of peri- signifies tumour nodules >5.0 cm in any dimension or
toneal disease volume and distribution, PET or PET-CT confluent nodules or layering of tumour. The number of
scans does not give additional information compared with nodules is not scored, and only the size of the largest
a regular, good-quality CT scan [29]. For mucinous carci- nodule is considered. The summation of LS score in
nomatosis, CT scan with two distinctive radiologic criteria each of the 13 abdominopelvic region is the PCI for
(segmental obstruction of the small bowel and presence of that patient. Thus, a minimum score of 1 and a maximum of
tumor nodules greater than 5 cm in diameter on small 39 (3 × 13) is possible [32].
bowel surfaces or directly adjacent to small bowel mesentery) The PCI has been found to be an independent prognostic
may distinguish patients with resectable disease from those factor for morbidity and survival in various disease types like
with non-resectable malignancy. But sensitivity of CT scan colorectal peritoneal metastases, gastric peritoneal metastases
for malignant nodules less than 5 mm, especially on small and in ovarian cancer [33–35]. In patients with colorectal PM
bowel surfaces, remains low [30]. Carcinomatosis with im- when the predicted PCI is >17–20, CRS and HIPEC should
plants less than 5 mm would not be imaged or would be not be offered, similarly for gastric cancer this cut off is a
underestimated in their distribution, especially in patients with predicted PCI of 12 [33, 34]. Exceptions to the prognostic
postoperative changes [31]. value of PCI include non-invasive diseases like low grade
pseudomyxoma peritonei and peritoneal mesothelioma. In
Peritoneal Cancer Index (PCI) (Fig. 1) these disease types, so long as a complete cytoreduction is
achieved, the initial PCI does not impact the survival as much
The PCI is a quantitative assessment of cancer distribution as the completeness of cytoreduction score [36]. The second
throughout the abdomen and the pelvis [32]. The PCI involves exception is the presence of invasive tumor deposits at crucial
integration of both peritoneal implant size & distribution of anatomic sites like the common bile duct, the base of the blad-
nodules on the peritoneal surface. To assess the distribution of der or pelvic side wall. The presence of residual unresectable
peritoneal surface disease, the abdominopelvic regions are disease at crucial anatomic sites overrides the favorable effect
examined, and for each of these 13 regions, a Lesion Size on the prognosis of low PCI score [37].

Fig. 1 Peritoneal carcinomatosis

index (PCI)
142 Indian J Surg Oncol (June 2016) 7(2):139–151

Completeness of Cytoreduction Score (CC score) involvement are absolute contraindications [45, 46]. Liver
metastases may also be a contraindication except for colorec-
In order to describe more precisely the type of cytoreduction tal carcinomatosis. Several studies have shown that the pres-
performed, Sugarbaker reported the CC score [38]. A CC-0 ence of few (one to three) liver metastases did not influence
score indicates that no visible peritoneal seeding exists survival if they could be surgically removed for PC from co-
following the cytoreduction; a CC-1 score indicates that lorectal cancer [47, 48]. For conditions where there is no cut
tumor nodules persisting after cytoreduction are <2.5 mm, off for PCI, the contraindications are
which is a nodule size thought to be penetrable by intracavity
chemotherapy and would, therefore, be designated a complete & Extensive bowel resection that is likely to compromise the
cytoreduction; a CC-2 score indicates tumor nodules between future quality of life e.g. 2 or more sites of segmental small
2.5 mm and 2.5 cm; and a CC-3 score indicates tumor nodules bowel obstruction, patients requiring a total gastrectomy
>2.5 cm or a confluence of unresectable tumor nodules at with a total colectomy
any site within the abdomen or pelvis. CC-2 and CC-3 & Involvement of pancreas head, bladder triagone, porta
cytoreductions are considered incomplete. Stricter criteria hepatis.
for complete cytoreduction are required for high-grade & Massive or diffuse involvement of pleural space [49]
non-mucinous neoplasms; a complete cytoreduction is restricted
to resection to absolutely no visible evidence of disease. The CC
score is a major prognostic indicator for PM from colorectal Technique of CRS and HIPEC
cancer, ovarian cancer, gastric cancer, pseudomyxoma peritonei
and peritoneal mesotheliomas as shown by several large Electro-Evaporative Surgery
multiinstitutional studies [33, 35, 36, 39].
This information is of less value to the surgeon in planning It is imperative that the surgeon dealing with PSM must de-
treatments than the PCI; the CC score is not available until velop the necessary technical skills and must be proficient in
after the cytoreduction is complete, whereas the PCI is avail- dissection with electrosurgery. High-voltage electrosurgery
able at the time of abdominal exploration [37]. Based on the leaves a margin of heat necrosis that is devoid of viable ma-
pre-operative evaluation the surgeon must be able to reason- lignant cells [50, 51]. Peritonectomies and visceral resections
ably predict the probability of a complete cytoreduction and in using traditional scissor and knife dissection will unnecessar-
cases where it is not deemed feasible, surgery should not be ily disseminate a large number of tumor cells within the ab-
undertaken. Though in certain cases, a palliative debulking domen. This minimizes the likelihood of persistent disease
can be done to provide symptomatic relief and/or prolong and decreases blood loss, which is extremely important in
survival, the goal needs to be defined before undertaking the these long duration surgeries. Besides, hemostasis has to be
procedure [40, 41]. absolute before starting the process of HIPEC, since during
that period, no hemostasis can be achieved and if there is
Contra-Indications to CRS and HIPEC persistent bleeding, it may be necessary to abort the HIPEC.
The commonest method of dissection is using the ball-tip
CRS and HIPEC is a major surgery for which the patient electrocautry as described by Dr. Sugarbaker [50]. However,
needs to have a good performance status and all other system- several surgeons have their preferences, including the bipolar
ic illness (cardiac, pulmonary etc.) should be under control. scissors, the ultrasonic scalpel or a combination of any of the
Absence of any of these would be a contraindication for the above.
procedure [42]. Age is not an absolute contraindication to the
combined treatment if the patient is fit to undergo major sur- Positioning of the Patient, Incision and Exposure
gery under general anesthesia, although surgical efforts and
chemotherapy dosages may have to be modified [44]. There Patient is placed in a supine position with the gluteal fold at
are also disease specific contraindications as discussed, for the end of the table to allow full access to the perineum. Either
e.g. a predicted PCI of >17–20 for colorectal cancer and >12 a modified lithotomy or a leg-split position is used with utmost
for gastric cancer would preclude a curative surgery [33, 34]. care to prevent pressure points and myonecrosis of the calf
For patients with colorectal cancer and ovarian cancer, pro- muscles [52]. Skin preparation is from the mid-chest to mid-
gression on neoadjuvant chemotherapy is not a contraindica- thigh with preparation of the genitalia and catheterization.
tion to CRS and HIPEC [35, 43]. Involvement of the urinary Abdominal cavity is opened through a midline incision
tract is also not an absolute contraindication provided com- from the xiphoid to the pubis. The old abdominal incision
plete tumor clearance can be attained and does not enhance the is often excised, and so is the umbilicus. Quite often,
morbidity from the procedure [44]. Multiple extra-abdominal these patients have had previous surgeries and caution
metastasis or massive suprarenal retroperitoneal lymph nodes needs to be exercised to prevent injury to intestines while
Indian J Surg Oncol (June 2016) 7(2):139–151 143

opening the abdomen. Generous abdominal exposure using Right Subphrenic Peritonectomy (Figs. 3 and 4)
a self-retaining retractor system is essential. Pre-operative and Stripping of the Glisson’s Capsule
assessment using imaging or laparoscopy usually gives a
roadmap to the steps involved in the surgery. If diaphrag- A firm traction on the peritoneal specimen helps to get the
matic stripping needs to be done, a xiphoidectomy will diaphragmatic muscle into view of the abdominal incision
help in better exposure and placements of retractor blades and the plane exposed is then dissected to proceed with the
[53]. When disease is extensive, a through exploration is subphrenic peritonectomy. There are several small vessels
performed to look for contraindication for CRS and no from the diaphragmatic muscles to the peritoneum and these
bowel should be resected till the surgical plan is finalized. need to be coagulated to minimize blood loss. The diaphrag-
matic vessels will be encountered just before the tendinous
portion of the diaphragm, and if possible, they should be pre-
Anterolateral Parietal Peritonectomy (Fig. 2) served. In invasive diseases, the tumor deposits may be infil-
trative and involve the diaphragmatic muscle, especially in the
If an anterolateral parietal peritonectomy is contemplated region of the tendinous portion. This may require resection of
based on either the pre-operative imaging or laparoscopy, an a part of the diaphragm which can be sutured with continuous
extra-peritoneal approach may facilitate dissection and save or interrupted non-absorbable monofilament suture. This su-
time. This extra-peritoneal dissection can be carried into the turing may be done immediately or can be deferred to after the
upper abdomen to continue into the sub-diaphragmatic plane HIPEC to let the chemotherapy circulate in the chest as well.
to perform the diaphragmatic peritonectomy [37] Once a part Caution must be exercised to avoid injury to the right hepatic
of the peritoneum along the costal margin is dissected off the vein and the IVC. Posterolaterally, the dissection proceeds
diaphragmatic muscles, the costal retractor blades can be over the upper part of the Gerota’s fascia and the adrenal,
placed to elevate the parities and this greatly facilitates the which constitute the base of the dissection (Fig. 5a,b).
dissection. At this stage, it is wise to make a small window Once the bare area of the liver is encountered superiorly, the
in the peritoneum to palpate the peritoneal surface. If there are diaphragmatic peritoneum turns onto and becomes continuous
extensive deposits over the anterior parietal peritoneum, a bi- with the Glisson’s capsule. In diseases like pseudomyxoma
lateral anterolateral parietal peritonectomy can be performed peritonei, it is not uncommon to encounter heavy disease over
by the extra-peritoneal approach. During this procedure, con- the liver, which can form a thick layer over the Glisson’s
stant traction on the abdominal wall and the specimen is im- capsule. Glehen et al. have described a very effective method
portant to expose the planes, where high voltage electrocau- of removing this disease [55]. Using either sharp or elec-
tery current is applied to dissect off the peritoneum of the trocautery, the sub-Glissonian space is entered and then by
parities. When the dissection reaches the paracolic region, bluntly moving the fingers in this plane, the Glisson’s
the dissection turns medially, facilitated by the medial traction capsule along with the disease can be effectively and swiftly
on the colon, and the dissection can proceed in the plane of the lifted off the liver surface (Figs. 6 and 7). This dissection is
fascia of Toldt. Superiorly, this dissection can blend into the greatly facilitated if the tumor specimen is maintained intact.
right and left subphrenic peritonectomy and inferiorly it can
continue into the complete pelvic peritonectomy [54].

Fig. 3 Subphrenic peritonectomy – peritoneum dissected off the diaphragm

Fig. 2 Anterolateral parietal peritonectomy on either sides
144 Indian J Surg Oncol (June 2016) 7(2):139–151

Fig. 4 Completed right subphrenic peritonectomy

Isolated deposits of tumour can be electrovaporated or dissect- Fig. 6 Finger dissection to strip off the Glisson’s capsule
ed off. Homeostasis can be achieved by placing a surgical pad
over the liver surface while the dissection proceeds to some
other area of the abdomen. Planning this part of the dissection adrenal. As the peritoneal reflection at the posterior aspect
in the earlier part of the cytoreduction ensures that adequate of the liver is divided, there is a risk of traumatising the
time is given for the hemostasis [55]. The dissection continues vena cava or the caudate lobe veins that pass between the
laterally on the right to encounter the perirenal fat and the vena cava and the segment 1 of the liver. Care should be
exercised to avoid injury to these structures, which can
cause significant bleeding.

Left Subphrenic Peritonectomy (Fig. 8)

The epigastric fat and peritoneum at the edge of the abdominal

incision is placed in firm traction and dissected of the posterior

Fig. 5 Base of the right subphrenic peritonectomy and subhepatic space;

5a – before; 5b - after Fig. 7 Completed Glisson’s capsule stripping
Indian J Surg Oncol (June 2016) 7(2):139–151 145

Fig. 8 Left subphrenic peritonectomy

rectus and as the dissection proceeds cephalad in the left upper

quadrant, the diaphragmatic muscle is visualised. The dissec-
Fig. 9 Lesser sac dissection – note the pancreatic capsule being stripped
tion proceeds posterolaterally to separate the peritoneum off off to clear the deposits in the lesser sac following a previous attempt at
the entire diaphragmatic surface, the left adrenal and the su- cytoreduction with recurrent lesions in the lesser sac
perior half of the perirenal fat. The splenic flexure of the colon
is severed from the left parabolic gutter and retracted medially posterolaterally after the spleen has been completely mobilised,
by dividing the peritoneum along the Toldt’s line. Again, most is safer and can help in avoiding injury to the pancreas.
of the dissection must be done with electrosurgery to ensure Splenectomy should not be performed in cases where the
minimal blood loss and adequate hemostasis. When the base spleen is not involved by tumor [56]. Some authors have sug-
of the dissection is reached, the left adrenal gland, pancreas gested that splenectomy ameliorates the hematologic toxicity of
and left perinephric fat along with the anterior surface of the HIPEC and reduces the requirement of growth factors and
transverse mesocolon is visualized [37]. platelets. [57].

Greater Omentectomy and Splenectomy Lesser Omentectomy and Hepatoduodenal Ligament

Clearance (Fig. 10 a and b)
The greater omentum is dissected off the transverse colon and
dissection proceeds below the layer of peritoneum covering
the transverse mesocolon to reach the lower border of the The gallbladder is removed in the routine fashion by the
pancreas (omental bursectomy). Occasionally, the pancreatic funds first approach with dissection and ligation of the cystic
capsule may need to be dissected, especially in recurrent cases artery and the cystic duct. The hepatoduodenal ligament can
where a previous omentectomy has been performed and there be heavily layered with tumour and dissection of the cystic
are deposits in the lesser sac and pancreatic capsule (Fig. 9). duct helps identify the bile duct and the plane between the
The greater omentectomy is completed by dividing the tumour and the portal structures. The plane is further devel-
branches of the gastroepiploic arcade to the greater curvature. oped by combination of blunt and bipolar dissection towards
If the omental disease is not significant, the gastroepiploic the duodenum and across the porta to the lesser omentum.
arcade may be preserved. When the left upper quadrant Attempt should be made to preserve the right gastric artery
peritonectomy has been performed, the structures beneath going into the lesser omental arcade. Posteriorly, the tumour
the left hemidiaphragm can be elevated and the short gastric layer along the posterior aspect of the porta hepatis is dissected
vessels can be divided under direct vision. If a splenectomy off bluntly towards the lesser omentum to connect it to the
needs to be performed, great care needs to be taken while layer dissected off anteriorly. Maintaining the tumour layer in
ligating and dividing the splenic vessels to avoid traumatising one piece helps in traction and complete removal. To continue
the tail and body of pancreas. Often, when there is significant the resection of the lesser omentum, the surgeon must separate
disease in the hilum of the spleen, the posterior approach the gastrohepatic ligament from the fissure that divides the
where the splenic vessels are approached and dissected liver segments 2 and 3 from segment 1. Tumour deposits over
146 Indian J Surg Oncol (June 2016) 7(2):139–151

made to preserve the arcade, the anterior vagus and the

left gastric vein, especially if the gastroepiploic arcade has
been divided and a splenectomy has been done.
The caudate lobe often overhangs the floor of the omental
bursa and retraction using a deep retractor is required to ade-
quately expose the area. Using a combination of blunt and
bipolar dissection, this layer of peritoneum is stripped off the
crus of diaphragm and the sub hepatic vena cava. In this way,
the entire omental bursectomy is completed and removed, if
possible, in continuity with the hepatoduodenal ligament
clearance. If there is large volume tumour in the sub pyloric
space, the lesser omentectomy specimen can be left in conti-
nuity with the antral region and a distal gastrectomy may be
performed to achieve complete clearance of this region.
A mention needs to be made regarding the resection of
the umbilical ligament. The umbilical ligament may be
surrounded by a variable amount of hepatic parenchyma
in the umbilical fissure. Sugarbaker has referred to this
bridge as ‘pont hepatique’ [58]. When there are deposits
on the peritoneum surrounding the umbilical ligament, it
becomes imperative to divide the pont hepatique covering
the umbilical fissure to expose the umbilical ligament in
its entirety (Fig. 11). The left hepatic artery or one of its
branches may be at risk of injury during the stripping of
the peritoneum in the umbilical fissure and special care
needs to be taken to avoid it.

Pelvic Peritonectomy (Figs. 12 and 13)

Pelvic peritoneum is quite often involved in peritoneal

spread of malignancies. To perform a pelvic peritonectomy,
the peritoneum from the posterior surface of the lower anterior
abdominal wall muscles is stripped from the midline to expose
the rectus abdomens muscles. After generously dissecting the
Fig. 10 Lesser omentectomy and hepatoduodenal ligament clearance;
10a – before; 10b – after

the caudate lobe may be dissected off or electrovaporated.

Care must be taken to identify and avoid injury to the acces-
sory or replaced left hepatic artery that may arise from the left
gastric artery. If the artery is embedded in the tumour and or its
preservation prevents clear exposure if the omental bursa, the
artery can be divided close to the liver [37].
The left lateral segment of the liver is mobilised by dividing
the left triangular ligament (if it is not already performed as a
part of left sub diaphragmatic peritonectomy), and the
segment is retracted to the right to facilitate exposure of
the entire hepatogastric ligament. The lesser omental bursa
is circumferentially dissected from the hepatic fissure, the
the caudate lobe and the arcade of the right and left gas-
tric arteries. This is done with a combination of electro-
surgery and digital dissection, with every attempt being Fig. 11 Divided Pont Hepatique exposing the umbilical ligament
Indian J Surg Oncol (June 2016) 7(2):139–151 147

ligated at the lower pole of the kidney and left on the pelvic
peritoneum. At this point, if a rectosigmoid resection is con-
templated, the dissection can proceed along the plane of
Toldt’s and the mesolectal fascia to mobilise the rectum. The
inferior mesenteric artery is ligated and divided and the sig-
moid colon can be stapled off at the required level. The rest of
the bowel can be packed off into the upper abdomen to give
adequate space for dissection in the pelvis [37].
In females, the deeper dissection in the pelvis proceeds
extraperitoneally till the uterine vessels are exposed, which
are ligated above the ureters [59]. The bladder is dissected
away from the cervix and the vagina and the vagina is
entered. The vaginal cuff is divided circumferentially and
the rectovaginal septum is exposed. The perirectal fat is
divided beneath the peritoneal reflection of the pouch of
Douglas (POD) so that all the tumour in this region is
removed intact with the specimen. When a rectal resection
is being performed, the rectal musculature is skeletonized
and stapler is fired to divide the rectum and complete the
pelvic peritonectomy. If the rectal wall and serosa is
spared of metastases, the pelvic peritoneum can be divided
Fig. 12 Rectum preserving pelvic peritonectomy along the lateral border of the mesorectum and along the
reflection onto the anterior surface of the rectum to com-
peritoneum on either sides to reach the psoas muscles, the plete the pelvic peritonectomy.
peritoneum is dissected on either side of the urinary bladder. The vaginal stump is closed at this stage (to prevent leakage
The urachus is identified and held and the peritoneum is of chemotherapy solution from the vagina during the HIPEC
stripped off the surface of the urinary bladder. The inferior phase) but the colorectal anastomosis is left to after comple-
limit of the dissection is the cervix in the females and the tion of HIPEC. However, it may be beneficial to mobilise
seminal vesicles in males. In the females, the round ligaments the left colon and take down the splenic flexure to facilitate
are divided extraperitoneally on either side and the ureters are a tension-free colorectal anastomosis after completion of
dissected away from the peritoneum. The ovarian vessels are HIPEC [37].

Small Bowel and Mesentry

The mesentery of the small intestine is a frequent site of

peritoneal metastases and this is amenable to treatment by
electrovaporisation or careful dissection to avoid injury to
the underlying vessels (Fig. 14). However, use of high-
voltage electrocautry on the small bowel serosa can lead
to small bowel fistulae. Sugarbaker et al. have classified
small bowel involvement into 5 types based on the extent
of invasion, the size of the tumor nodule and its anatomic
location on the bowel wall [60].

& Type 1: Non-invasive nodules that can be removed with a

curved Mayo scissors.
& Type 2: Small invasive nodules on the anti-mesenteric
portion of the small bowel. These involve only the
seromuscular layer and require partial thickness bowel
resection
& Type 3: Moderately sized invasive nodules on the anti-
Fig. 13 Pelvic peritonectomy with anterior resection below the reflection mesenteric portion of the small bowel which require a full
of the pouch of Douglas thickness elliptical resection of the bowel wall
148 Indian J Surg Oncol (June 2016) 7(2):139–151

[67]. Care should be taken to avoid the left ureter and

the vaginal stump in females while performing a stapled
anastomosis.

Partial/total Gastrectomy

Presence of tumor around the stomach/and or involvement

of the left gastric artery may necessitate a total or a partial
gastrectomy. Sugarbaker initially used a staged procedure
performing a high jejunostomy to drain the enteric secre-
tions followed by a Roux-en-Y anastomosis few months
later [68]. Recent studies have shown that in experienced
centres, immediate restoration of gastrointestinal continuity
is feasible and safe [69, 70].
Fig. 14 Localized peritonectomy over mesentry to remove a mesenteric
deposit Colectomy, Distal Pancreatectomy, Hepatic Resection

Resection of the right or transverse colon is often required in

& Type 4: Small invasive nodules at the junction of the small patients with extensive omental deposits or bowel surface/
bowel and its mesentry, if possible can be removed with- mesenteric deposits. In cases of more extensive disease, a total
out damaging the vascular supply and segmental bowel or subtotal colectomy maybe required. A right hemicolectomy
resection could be avoided. Other require a segmental may not be necessary for dealing with an appendiceal primary
resection in patients with pseudomyxoma peritonei [71]. A distal pan-
& Type 5: Large invasive nodules which require a segmental createctomy maybe required in patients with involvement of
resection with a generous margin of bowel and mesentry the distal pancreas with or without splenic hilar involvement,
on either side. pancreatic capsule involvement or due to iatrogenic injuries
[72]. In experienced centres this procedure has shown to be
safe when performed as a part of CRS and HIPEC, though it
increases the morbidity, mortality is not increased [73, 74].
Resection of Contiguous Structures and Viscera
In patients with ovarian cancer, morbidity caused by pan-
creatic fistula may cause a delay in starting adjuvant che-
Full Thickness Diaphragm Resection
motherapy [75]. Similarly, non- anatomic liver resection
may be required in patients with extensive deposits on
When there is tumor infiltration of the diaphragmatic muscle,
the liver surface. In patients with ovarian cancer, synchro-
a full thickness resection is needed. This can be performed
nous resection of intraparenchymal liver metastases can be
with a bipolar scissors or electrocautery or Mayo scissors.
performed with CRS, especially in patients with solitary
When the tumor is close to the vascular structures on the right
liver metastases [76, 77].
side, complete vascular control of the hepatic vessels should
be taken prior to a subphrenic peritonectomy [61].
Morbidity of Multivisceral Resection

Resection of the Rectosigmoid Colon Several studies have shown that 2 or more bowel anastomosis
has a significant impact on morbidity of patients undergoing
Resection of the rectosigmoid colon is often necessary to CRS and HIPEC [78–80]. Increasing number of peritonectomies
achieve a complete cytoreduction. Hertel et al. showed that also increase the morbidity. Only the number of anastomoses
in patients with advanced ovarian cancer, with suspected seem to have an impact on morbidity not the number of organs
rectal serosal invovlment, 73 % of the patients had residual resected [81].
disease when a recto-sigmoid resection was not performed
with a pelvic peritonectomy [62]. Several studies have
shown that it does not increase the morbidity of CRS and Conclusions
not all cases require a diverting ileostomy. [63–66] When
10–15 cm of the rectum is preserved, an ileostomy can be CRS is a complex procedure associated with a prolonged
avoided. Sugarbaker has described the technique of inverting learning curve. A surgeon perfoming CRS must be com-
the stapled anatamosis with a layer of interrupted silk sutures fortable in operating on all areas of the abdominal cavity
Indian J Surg Oncol (June 2016) 7(2):139–151 149

and must be familiar with the anatomy of various regions. 18. Jacquet P, Sugarbaker PH (1996) Clinical research methodologies
in diagnosis and staging of patients with peritoneal carcinomatosis.
Patients selection is as important as the technical skill
Cancer Treat Res 82:359–374
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optimal results: potentially curative procedures with con- 20. Ronnett BM, Shmookler BM, Sugarbaker PH, Kurman RJ (1997)
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menclature, and relationship to mucinous borderline (low malignant
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chemotherapy: retrospective analysis of 523 patients from a
multicentric French study. J Clin Oncol 28(1):63–68
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