**5. Description of the technique for cytoreductive surgery**

In ovarian cancer most of the authors recommend a selective peritonectomy technique and not a total peritonectomy, but in our hospital we prefer performing a total extraperitoneal (Sugarbaker) peritonectomy because we have more experience with it and we consider it more radical based on our results [22, 23]. An example of extraperitoneal peritonectomy can be seen in **Figures 1** and **2**.

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cancer.

**Figure 2.**

consists of:

diaphragm;

• cholecystectomy

of the omental bursa

• liver hilum lymph node dissection

• resection the peritoneum of the Morison space

*Cytoreductive Procedures and HIPEC in the Treatment of Advanced Ovarian Cancer*

We start by detaching the peritoneum completely without opening it by entering a plane located between the peritoneum and the rectus sheath. We continue in this plane laterally until reaching the peritoneum, cranially until the Glisson's capsule and inferiorly we resect the peritoneum covering the bladder with the uterus and the two adnexae, with or without the rectum. As patients usually come to us after a staging laparotomy performed elsewhere, we start by resecting the previous scars which are the most common sites of future relapses. We usually start below the umbilicus as this is the place where we can develop the correct plane at greater ease. Once the round ligament is cut at the level of the deep inguinal ring we can dissect easily laterally until reaching the retroperitoneum and exposing the iliac vessels and the ureters. We then develop the plane cranially. Sometimes splenectomy is necessary if implants are seen on it or close to it, but it is not indicated as a rule in ovarian

*Sugarbaker extraperitoneal peritonectomy view once the peritoneal cavity is opened.*

Once the peritoneum is detached completely cranially and laterally, we enter the peritoneal cavity. A first resection specimen is constituted by the median scar, the umbilicus, the round ligament of the liver which is cut at the level of Rex's recess, the falciform ligament and the urachal fold down to the bladder. The remaining peritoneum will be split into four quadrants. Completing the peritonectomy of the right upper quadrant is considered the most difficult as it

• resecting the diaphragmatic peritoneum, sometimes with a piece of

• dissection of the Glisson's capsule, if affected, with the eventual metastases;

• right colo-epiploic takedown with dissection of the posterior peritoneal sheath

*DOI: http://dx.doi.org/10.5772/intechopen.96405*

**Figure 1.** *Sugarbaker extraperitoneal peritonectomy.*

*Cytoreductive Procedures and HIPEC in the Treatment of Advanced Ovarian Cancer DOI: http://dx.doi.org/10.5772/intechopen.96405*

### **Figure 2.**

*Ovarian Cancer - Updates in Tumour Biology and Therapeutics*

oncologist to perform HIPEC with a preventive thinking in mind.

sis performed by Helm et al. [14].

peritoneal biopsies reveal residual disease.

treatment – basically a salvage procedure.

recurrence.

cytoreductive procedures and HIPEC can be performed as can be seen in the analy-

Another moment for HIPEC and cytoreduction is after neoadjuvant chemotherapy, because most ovarian cancers respond well to chemotherapy and become operable after a neoadjuvant treatment. The only disadvantage is that it might downsize the peritoneal implants, rather than really downstage the tumor and thus hide implants that otherwise would have been resected, increasing the risk for

HIPEC can also be performed as a consolidation therapy after neoadjuvant chemotherapy, meaning that it is performed during a second look laparotomy when

Another occasion on which these procedures might become useful in ovarian cancer is when a peritoneal relapse is diagnosed and surgery is performed usually after a new course of neoadjuvant chemotherapy which will also determine the

Finally, the last situation in which we would perform HIPEC is as a last resort

In ovarian cancer most of the authors recommend a selective peritonectomy technique and not a total peritonectomy, but in our hospital we prefer performing a total extraperitoneal (Sugarbaker) peritonectomy because we have more experience with it and we consider it more radical based on our results [22, 23]. An example of

chemotherapeutic agent to be used based on the response of the tumor.

**5. Description of the technique for cytoreductive surgery**

extraperitoneal peritonectomy can be seen in **Figures 1** and **2**.

The first such moment and the one in which cytoreduction and HIPEC give the best chances of survival is when the diagnosis is made, if complete cytoreduction can be achieved [2]. In the moment of diagnosis, depending on the extent of the disease we can talk about prophylactic HIPEC or conventional HIPEC in later stages [19]. Prophylactic HIPEC in ovarian cancer refers to stages I and II in which we have a cytology sample which is positive for tumor cells, which suggests an increased risk for peritoneal relapse and a decision is made together with the patient and the

**114**

**Figure 1.**

*Sugarbaker extraperitoneal peritonectomy.*

*Sugarbaker extraperitoneal peritonectomy view once the peritoneal cavity is opened.*

We start by detaching the peritoneum completely without opening it by entering a plane located between the peritoneum and the rectus sheath. We continue in this plane laterally until reaching the peritoneum, cranially until the Glisson's capsule and inferiorly we resect the peritoneum covering the bladder with the uterus and the two adnexae, with or without the rectum. As patients usually come to us after a staging laparotomy performed elsewhere, we start by resecting the previous scars which are the most common sites of future relapses. We usually start below the umbilicus as this is the place where we can develop the correct plane at greater ease. Once the round ligament is cut at the level of the deep inguinal ring we can dissect easily laterally until reaching the retroperitoneum and exposing the iliac vessels and the ureters.

We then develop the plane cranially. Sometimes splenectomy is necessary if implants are seen on it or close to it, but it is not indicated as a rule in ovarian cancer.

Once the peritoneum is detached completely cranially and laterally, we enter the peritoneal cavity. A first resection specimen is constituted by the median scar, the umbilicus, the round ligament of the liver which is cut at the level of Rex's recess, the falciform ligament and the urachal fold down to the bladder. The remaining peritoneum will be split into four quadrants. Completing the peritonectomy of the right upper quadrant is considered the most difficult as it consists of:


• selective peritonectomy of the space between the caudate lobe, the inferior vena cava and the right diaphragmatic crux

In the left upper quadrant, the peritonectomy means:


In the lower abdomen the peritonectomy includes:


In the central part of the abdomen the small intestine is examined carefully on both sides. Severely affected portions of the small bowel are resected carefully, keeping in mind in mind the risk for short bowel and taking away as little bowel as possible. Mesenteric implants are either resected or Argon beam coagulated. Atypical resections of the stomach can also be performed with the use of linear staplers.

Keeping in mind that the cytoreduction is usually followed by HIPEC we are faced with some delicate decisions regarding the anastomoses we perform. For small bowel we perform a 2-layer latero-lateral continuous suture without stoma. For colorectal anastomoses we perform a mechanical anastomosis using a circular stapler and protecting the anastomosis with a colostomy which we prefer to an ileostomy. And finally, there are cases where we do not perform an anastomosis but rather an end colostomy or ileostomy. These are mostly CC1 cases, posterior pelvic exenteration cases or total colectomy cases in fragile patients, even with a CC0 resection where an anastomosis would be too risky due to the status of the patient.

**117**

and the drains are left in place.

*Cytoreductive Procedures and HIPEC in the Treatment of Advanced Ovarian Cancer*

**6. Assessing the completeness of cytoreduction – the radicality score**

It is considered the most important prognostic score, being estimated at the end of the cytoreductive stage. The penetrability of intraperitoneal chemotherapy is possible for lesions up to 2.5 mm. For most intraperitoneal neoplasms, complete CC0 cytoreduction is required, the CC1 score being considered acceptable only for peritoneal pseudomyxoma, a neoplasm with reduced aggressiveness. The radicality of resection classification is as follows: CC0 – no residual disease, CC1 – residual lesions smaller than 0,25 cm, CC2 – residual lesion between 0,25 and 2,5 cm and

The impossibility of a radical surgery CC0-CC1 can determine the change of the operative strategy, either towards a palliative debulking surgery, or towards giving up any gesture of excision. In chemotherapy "naive" tumors, the maximum cytore-

For reasons related to the safety of handling cytostatic substances, most HIPEC teams in Europe, including our team use the "closed abdomen" technique in which the abdomen is closed permanently or only temporarily (the skin), with 4 drains

In short, the Rand Performer HT device that we use in our current activity, has the following components: 1) a heater or heat exchanger; 2) a pump system, which includes one or two peristaltic pumps; 3) a tank containing the infusion solution; 4) a circuit that distributes the drugs and heated fluid to the patient's peritoneal cavity. In 1999 the Italian Biomedical Company (RanD Biotech SRL, Medolla, Italy) was the first to develop a device dedicated to HIPEC, used especially for the treatment by hyperthermic perfusion of the peritoneal cavity. The most important advantage of this device (Performer HT) is its portability and adaptability for various purposes, as it can also be used to infuse isolated anatomical regions or organs, such as the treatment of an isolated limb or the separate infusion of the liver or lung. The Performer HT device ensures a flow rate of 100–2000 ml/min and it has up to 8 temperature monitoring lines in various areas of the peritoneal cavity, which has the ability to measure temperatures between 28 °C and 46 °C. In our practice we use tubes with a diameter of 28 Fr, two for inlet (1 - subdiaphragmatic and 1 - in the pelvis) and two for the outlet (1 - subdiaphragmatic and 1 - in the pelvis). We also use two lines for monitoring the intraabdominal temperature mounted in the pelvis and in the supramesocolic space. In terms of the perfused solution, we use 4–6 liters of warm transport solution (2/3 Ringer, 1/3 Voluven). Once an optimal infusion rate (> 800 ml/min) and an optimal intraperitoneal temperature around 42-43 °C is reached, the cytotoxic drugs are administered. We use Cisplatin (43 mg/L solution/m2) or Doxorubicin (15 mg/L solution) for carcinomatosis due to serous ovarian cancer. The duration of chemoperfusion is between 60 and 90 minutes. At the end of the procedure, the abdomen is rinsed with 3 liters of saline

As to the choice of the chemotherapeutic drug, it takes into account the sensitivity of the tumor to platinum salts, which can be seen preoperatively by the response of the tumor to the neoadjuvant chemotherapy. Platinum-sensitive patients will follow the Cisplatin protocol, Platinum-resistant patients, the Doxorubuicin protocol.

• Cisplatin (43 mg/L solution/m2) - for Platinum CEO sensitive.

• Doxorubicin (15 mg/L solution) - for CEO resistant Platinum.

*DOI: http://dx.doi.org/10.5772/intechopen.96405*

CC3 – residual lesions larger than 2,5 cm [18].

**7. Description of the HIPEC procedure**

inside, coupled to extracorporeal circulation device.

duction with HIPEC followed by adjuvant CT is to be considered.

*Cytoreductive Procedures and HIPEC in the Treatment of Advanced Ovarian Cancer DOI: http://dx.doi.org/10.5772/intechopen.96405*

## **6. Assessing the completeness of cytoreduction – the radicality score**

It is considered the most important prognostic score, being estimated at the end of the cytoreductive stage. The penetrability of intraperitoneal chemotherapy is possible for lesions up to 2.5 mm. For most intraperitoneal neoplasms, complete CC0 cytoreduction is required, the CC1 score being considered acceptable only for peritoneal pseudomyxoma, a neoplasm with reduced aggressiveness. The radicality of resection classification is as follows: CC0 – no residual disease, CC1 – residual lesions smaller than 0,25 cm, CC2 – residual lesion between 0,25 and 2,5 cm and CC3 – residual lesions larger than 2,5 cm [18].

The impossibility of a radical surgery CC0-CC1 can determine the change of the operative strategy, either towards a palliative debulking surgery, or towards giving up any gesture of excision. In chemotherapy "naive" tumors, the maximum cytoreduction with HIPEC followed by adjuvant CT is to be considered.
