The peritonectomy procedure described by Sugarbaker is adopted. In the operating room, the patient is put in a supine position with gluteal folds advanced to the break on the operating table to allow full access to the perineum during the surgical procedure. This position is essential to avoid intraoperative skin or muscle necrosis. The weight of the legs must be directed to bottom of the feet by positioning the footrests so that minimal weight is borne by the calf muscle. Myonecrosis within the posterior compartment of the leg may occur unless the legs are protected properly. A 3-way bladder catheter and a large-bore silastic nasogastric tube are positioned. Abdominal skin preparation is from mid chest to mid thigh as well as the external genitalia, including vagina. The abdomen is opened from xyphoid to pubis. Generous abdominal exposure is achieved through the use of a Thompson Self-Retaining Retractor.

A ball-tip electrosurgical handpiece is used to dissect the tumour on peritoneal surfaces from normal tissue. The electrosurgery is used on pure cut at high voltage. The 2 mm ball-tip electrode is used for dissecting on visceral surfaces, including stomach, small bowel, and colon. When more rapid tumour destruction is required, the 5 mm ball-tip can be used.

Schematic and in vivo huge peritoneal neoplasticdiffusion

Surgical Steps

Each procedure that composes the peritonectomy technique has a definite resection that requires an orderly sequence of surgical maneuvers to create an optimum cytoreduction. One or more of following steps can be performed depending on the extension of primary surgical staging or disease extension at the time of SLO, in order to achieve optimal residual status.

1. greater omentectomy, right parietal peritonectomy and right colon resection
2. left upper quadrant peritonectomy, splenectomy and left parietal peritonectomy
3. right upper quadrant peritonectomy and Glissonian's capsule resection
4. lesser omentectomy, cholecystectomy, stripping of omental bursa and antrectomy
5. pelvic peritonectomy with sigmoid colon resection with or without hysterectomy and bilateral salpingo-oophorectomy;
6. other intestinal resection and/or abdominal mass resection.
7. bowel anastomoses.

Upper abdomen quadrant peritonectomy: A) Preoperative CTscan; B) Complete cytoreductive surgery of the pepato-duodenal ligament, vena cava, Morrison pouch lesser omentum and gallbladder; C) Postoperative CTscan
Lower abdomen quadrant peritonectomy: A) Preoperative CTscan; B) Complete cytoreductive surgery; C) Postoperative CTscan