Innovative technology of total parietal peritonectomy for peritoneal carcinomatosis

Full Text

BACKGROUND

Cytoreductive surgical interventions play a key role in the complex treatment of patients with peritoneal carcinomatosis of various etiologies [1, 2]. These include various combinations of resections, extended lymphodissection, and peritonectomy. The technical complexity, duration, and traumatic nature of cytoreductive surgeries naturally cause not only a high incidence of postoperative complications and lethality but also significant risks of iatrogenic damage to vital anatomical structures [3–6]. This type of surgery mainly aims to eliminate peritoneal carcinomatosis, remove primary and metastatic tumor foci as much as possible, and create favorable conditions for effective systemic antitumor therapy [7–10].

The study aimed to develop the technology of pneumodissection of the peritoneum using carbon dioxide insufflation based on experimental studies and evaluate its efficiency.

MATERIALS AND METHODS

The study was conducted with the permission of the Independent Ethical Committee of the S.M. Kirov Military Medical Academy on 10 unembalmed cadavers whose cause of death was unrelated to tumors of the abdominal cavity and pelvic organs. Karl STORZ Thermoflator 26432020-1 Insufflator (registration certificate 2011/09444, dated 21.12.2017); 20 L carbon dioxide cylinders; 1.5 m long, 1 cm diameter silicone lines; 18 G Seldinger puncture needle; and 16 G flexible polypropylene bougie were used.

RESULTS

The experimental study allowed the development and validation of total parietal peritonectomy based on the pneumodissection of the peritoneum using carbon dioxide insufflation. The results allowed us to define the concept of the new technology as a method of tissue separation based on carbon dioxide insufflation into the connective tissue layers of the retroperitoneal space to safely dissect anatomical structures. In the literature, a clinical case of carbon dioxide insufflation use in the course of cytoreductive surgical intervention was reported; however, it lacks a detailed description of the operative technique and topographic and anatomical justification, which, undoubtedly, any surgical intervention should be based on [11].

Taking into account the topographic and anatomical features of the parietal peritoneum, it is reasonable to distinguish three main types of peritonectomy using pneumodissection technology (Fig. 1):

1. Peritonectomy of the lateral abdominal walls
2. Pelvic peritonectomy
3. Diaphragmatic peritonectomy

 

Fig. 1. General scheme of the pneumodissection of the parietal peritoneum: I, peritonectomy of the lateral abdominal walls; II, diaphragmatic dissection; III, pelvic peritonectomy

 

To perform pneumodissection, an 18 G Seldinger puncture needle must be used, which is inserted under the parietal peritoneum at an angle of 10°–30° and at the end of which is placed in the subperitoneal vascular-free fascial layer. Gas insufflation creates an air cushion, and after the formation, the needle was changed to a flexible bougie that serves as a 16 G manipulation catheter (Fig. 2). The bougie is advanced with fan-like progressive movements in the required direction in the presence of continuous gas supply by the insufflator, ensuring pneumodissection of the peritoneum. During the procedure, constant visual control of movements in the dissection plane is necessary to prevent iatrogenic damage to vital anatomical structures.

 

Fig. 2. CO₂ distribution in the subperitoneal space during insufflation

 

To achieve optimal exposure of the operating field, revision of the abdominal cavity organs and preparation of the necessary equipment are performed after a midline laparotomy and installation of retractors.

Pneumodissection of the peritoneum of the lateral abdominal walls should be started after puncturing the preperitoneal space in the peritoneal region at a distance of 1–2 cm from the edge of the laparotomy incision. Gas insufflation is initiated in cranial and caudal directions and the direction of the lateral abdominal canals. Fan-like progressive movements of the manipulation bougie and dynamic visual control of its location in the dissection plane ensure the safety of the procedure. The cranial border of pneumodissection is the lower bundles of the rib part of the diaphragm; caudal border, iliac fossa; and dorsal border, conditional Told line (Fig. 3).

 

Fig. 3. Pneumodissection of the peritoneum of the lateral abdominal walls

 

Pelvic peritonectomy should be understood as the removal of the parietal peritoneum located within the anatomical boundaries of the pelvic cavity. Topographic and anatomical features of the pelvic peritoneum, different planes of its course, and variety of visceral and neurovascular structures make it necessary to perform pneumodissection of the pelvic peritoneum from different accesses. As shown in the results of literature analysis and topographic and anatomical studies, distinguishing three key directions of pneumodissection at pelvic peritonectomy, namely, lateral, anterior, and posterior, is reasonable (Fig. 4).

 

Fig. 4. Gas insufflation directions during pelvic peritonectomy. Area 1 indicates gas diffusion from the anterior access; 2 and 3, direction of gas diffusion from the lateral access; 4, direction of dissection from the posterior access

 

Pneumodissection of the pelvic peritoneum in the lateral direction should be started after puncturing the peritoneum in the iliac fossa at the level of the anterior superior iliac spine. The bougie should be advanced parallel to the internal iliac vessels in the direction of the pelvic diaphragm. Owing to the well-developed subperitoneal tissue, the peritoneum was dissected without serious technical difficulties. As a result, performing safe mobilization of ureters, external and internal iliac, and gonadal vessels is possible. The caudal border of pneumodissection in the lateral direction in women is the cervix and in men the seminal vesicles. During pneumodissection in this area, the direction of catheter advancement in the dissection plane must be controlled.

When performing pneumodissection of the pelvic peritoneum in the posterior direction, the peritoneum is punctured at a distance of 15–20 mm from the aortic bifurcation in the caudal direction. The manipulation catheter is advanced along the common iliac vessels, connecting the posterior and lateral directions of pneumodissection. If interventions on the pelvic organs are necessary, the advancement of the manipulation bougie along the sacrum in the direction of the pelvic diaphragm mobilizes the posterior and partially posterolateral surfaces of the mesorectum.

Anterior pneumodissection of the pelvic peritoneum should be started from a point on the posterior surface of the rectus abdominis 2 cm above the bosom articulation and continued toward the pelvic diaphragm. The caudal boundary of peritoneal mobilization in women is the vesico-uterine recess and in men the vesico-rectal recess (Fig. 5).

 

Fig. 5. Pneumodissection of the pelvic peritoneum

 

Diaphragmatic peritonectomy is the most technically difficult stage of cytoreductive intervention because of the morphofunctional features of the diaphragm, its variant anatomy, close topographic and anatomic relationship of the liver and large blood vessels, and high risks of diaphragm perforation with inevitable tumor dissemination into the pleural cavity. These circumstances largely determine the need to develop low-traumatic methods of peritonectomy, which, in our opinion, should include pneumodissection technology.

Three key directions of pneumodissection of the diaphragmatic peritoneum are as follows: from the side of the rib, the sternal part of the diaphragm, and from the area of the hepatorenal recess (Fig. 6).

 

Fig. 6. Main directions of gas spreading when performing diaphragmatic peritonectomy. Area 1 indicates the direction of pneumodissection in the area of the rib part of the diaphragm; 2, the direction in the area of the sternal part of the diaphragm; 3, the direction in the area of the hepatorenal recess; 4, gas spreading in the area nuda

 

The dissection of the peritoneum of the rib part of the diaphragm should be started from the points of fixation of its lower bundles. The manipulation bundle is advanced along the plane of the diaphragm in the cranial direction.

Fan-shaped progressive movements of the manipulation bougie and visual control of its location in the plane of pneumodissection ensure the safety of the procedure. The border of dissection is the right triangular ligament of the liver on the right and gastroesophageal ligament on the left. Pneumodissection of the diaphragmatic peritoneum from the sternal side should be started from the projection of the apex of the sternal triangle, 10–15 mm from the edge of the laparotomy incision. The dissection is performed in the cranial direction, and its border is the left venous ligament of the liver. Pneumodissection of the diaphragmatic peritoneum from the area of the hepatorenal pocket should be performed 2 cm lateral to the outer edge of the right kidney projection.

The catheter is advanced in the cranial direction, with the right triangular ligament of the liver being the border of pneumodissection (Fig. 7).

 

Fig. 7. Pneumodissection of the parietal peritoneum of the left diaphragmatic dome

 

Thus, consistent performance of the above-described stages of pneumodissection allows the total mobilization of the parietal peritoneum during peritonectomy.

CONCLUSIONS

Pneumodissection of the peritoneum using gas insufflation is a new and promising technique with several advantages: ease of performance, low trauma, high safety, and probably ablative, which can potentially create conditions for the prevention of inadvertent dissemination of tumor cells through the abdominal cavity.

Experimental data allow us to conclude that pneumodissection of the peritoneum using carbon dioxide insufflation is an effective method of performing total parietal peritonectomy; however, further studies are needed to evaluate the effectiveness of this technology and its possible introduction into cytoreductive surgical interventions in patients with peritoneal carcinomatosis.

ADDITIONAL INFORMATION

Funding. The study had no external funding.

Conflict of interest. The authors declare that there are no obvious and potential conflicts of interest related to the publication of this article.

Ethical review. The study was approved by the local ethical committee of the S.M. Kirov Military Medical Academy, Ministry of Defense of Russia (Protocol No. 256 from 23.11.2021).

Authors’ contribution. All authors contributed substantially to the study and article, read and approved the final version before publication.

About the authors

Vadim A. Prosvetov

Military Medical Academy

Email: prosvetovvma@yandex.ru
SPIN-code: 1717-7735
Scopus Author ID: 907465

Resident of the General Surgery Department

Russian Federation, Saint Petersburg

Dmitry A. Surov

Military Medical Academy

Email: sda120675@mail.ru
SPIN-code: 5346-1613
Scopus Author ID: 445844

M.D., D.Sc. (Medicine), Associate Professor

Russian Federation, Saint Petersburg

Ivan V. Gaivoronsky

Military Medical Academy

Email: nichiporuki120@mail.ru
SPIN-code: 1898-3355
Scopus Author ID: 293462

M.D, D.Sc. (Medicine), Professor

Russian Federation, Saint Petersburg

Van Thu Nguyen

Military Medical Academy

Author for correspondence.
Email: thuhvqy@gmail.com
SPIN-code: 6895-5893
Scopus Author ID: 907139

Adjunct at the Naval Surgery Department

Russian Federation, Saint Petersburg

References

Supplementary files