Staging laparoscopy and Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) for peritoneal metastasis: safe access to the abdomen

Abstract

BackgroundPressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is an innovative drug delivery technique. Most common indication is palliative therapy of peritoneal metastasis of gastrointestinal and gynecological origin in the salvage situation. Access to the abdomen is the critical step of the procedure, since most patients had previous surgery. Potential pitfalls include non-access because of adhesions, bowel access lesions and postoperative subcutaneous toxic emphysema.MethodsWe propose a technique, the “finger-access technique” that might prevent largely these pitfalls. A minilaparotomy of 3 cm is performed in the midline, a finger introduced into the abdomen and a 5-mm double-balloon trocar (no Hasson trocar) is placed under finger protection at some distance of the first incision. The fascia of the minilaparotomy, not the skin, is then closed. The abdomen is insufflated with CO2 and tightness is controlled with saline solution in the minilaparotomy. A second 10–12 mm trocar is then introduced under videoscopic control. The first trocar is then visualized through the second one to exclude a bowel lesion during first access.Results and conclusionsIn our hands, this access technique has shown to be safe and effective.

Feasibility and Safety of Oxaliplatin-Based Pressurized Intraperitoneal Aerosol Chemotherapy With or Without Intraoperative Intravenous 5-Fluorouracil and Leucovorin for Colorectal Peritoneal Metastases: A Multicenter Comparative Cohort Study

“…26 For this reason, clinical teams continue to search for improved means of access to the peritoneal cavity to avoid complications and deterioration of therapeutic management. 27 In our study, intraoperative intravenous 5-FU/L combined with PIPAC-Ox did not increase the postoperative complication rate compared with PIPAC-Ox alone. Systemic chemotherapy using oxaliplatin and 5-FU/L has shown great success in the management of metastatic colorectal cancer.…”

Pressurized intraperitoneal aerosol chemotherapy, reasons for interrupting treatment: a systematic review of the literature

“…Moreover, patients who are eligible for PIPAC treatment often have prior abdominal surgery as CRS or HIPEC. This may explain the observed failure rate which is higher due to attempts to access the abdomen to perform PIPAC [ 37 , 38 ].…”

“…[ 43 ] found that bowel injury related to a Veress needle or trocar insertion was the most common complication. For this reason, clinical teams continue to search for improved means of access to the peritoneal cavity to avoid complications and the deterioration of therapeutic management [ 37 ].…”

Radiologist Checklist for Selecting Patients to Undergo PIPAC (Pressurized IntraPeritoneal Aerosol Chemotherapy)

“…According to a systematic examination, access to the abdomen is largely dependent on patient selection and surgical ability, and after cytoreductive surgery, peritonectomy, and HIPEC, it shows a non-access rate higher than after other procedures [ 17 ].…”