Total Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adenocarcinoma of the Appendix

Open cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA); however, it is associated with substantial morbidity. We present a case of a total laparoscopic R0-CRS-HIPEC for MAA. CRS included right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oophorectomy, excision of the round and falciform ligaments, and stripping of the peritoneum of the right diaphragm, followed by HIPEC through single inflow and outflow catheters. The operative time was 380 minutes, and the estimated blood loss was 100 mL. There was no postoperative morbidity. The patient was discharged on postoperative day 8. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has emerged as the procedure of choice for selected patients with MAA. ¹ Usually performed through a large midline incision, CRS-HIPEC is associated with a substantial rate of morbidity and mortality. ^2–3 The role of laparoscopic approach as alternative to the open surgical approach for this indication is not yet well established. In this video, we present a case of a 52-year-old Caucasian female with a history of Child A hepatic cirrhosis secondary to hepatitis C. The patient initially presented with right lower quadrant abdominal pain. A CT scan was obtained and revealed, as shown in the video, a dilated appendix; there was also peritoneal deposit on the right upper quadrant. The patient underwent laparoscopic appendectomy during which, the appendix was found to be ruptured and laparoscopic biopsy of the right upper quadrant peritoneal deposit. Pathological examination of the specimens revealed well-differentiated adenocarcinoma. The patient was referred to surgical oncology, and the case was discussed on multidisciplinary tumor board. The consensus agreement of the tumor board was to offer the patient CRS-HIPEC. The possibility of proceeding with a laparoscopic approach was based an attempt to minimize postoperative morbidity related to the patient cirrhosis ⁴ and to facilitate exposure to the right upper quadrant peritoneum and diaphragm. An informed consent was obtained. The procedure was performed through four trocars, as shown in the video. A 5-mm infraumbilical trocar was used for the camera, 5 mm right upper quadrant and left lower quadrant was used as working ports, and a 12-mm trocar in suprapubic position was used as working port and for stapler access. Laparoscopic exploration of the abdomen showed a peritoneal cancer index of 8 ⁵ with peritoneal deposit over the right upper quadrant, over the liver surface by the gallbladder and on the omental surface. There was minimal serous ascites. The surgical resection started with a right hemicolectomy using a medial to lateral approach with the mesenteric vessels dissected using electrocautery and stapled using endomechanical vascular load (2.5 mm) stapler first before the right colon was mobilized along the line of Toldt using a radiofrequency-energy-based cutting and sealing device. The distal ileum was divided about 10 cm from the ileocecal valve using endomechanical 3.5-mm stapler. Next, bilateral salpingo-oophorectomy was performed by dissecting the ovarian vessels using the Maryland dissector, and then, the division of the ovarian vessels using endomechanical 2.5-mm staplers. The tubes and round ligaments were divided using the energy-based cutting and sealing device. There was no evidence of gross disease in the pelvis. After that, the round ligament was divided and the falciform ligament was resected. Next, we proceeded with total omentectomy with the division of the omental attachment to the transverse colon and the greater curvature of the stomach respecting the transverse mesocolon and the gastroepiploic arcade. Hemostasis secured using the radiofrequency-energy-based cutting and sealing device. At this point, our attention was directed to the peritoneal deposit over the right upper quadrant and the right diaphragm. The peritoneal deposits were infiltrated the underlying diaphragm. We proceeded with partial peritonectomy with partial resection of invaded underlying muscle fibers. The point of entry of the peritonectomy was started using electrocautery in a grossly normal looking spot area about 1 cm away from the gross disease and pursued using the radiofrequency-energy-based cutting and sealing device. The laparoscopic approach allowed us to a relative easy access to this uppermost area of the abdomen usually with limited exposure in an open approach as per the presence of the liver and allowed us to perform a complete resection with no microscopic residual tumor (RO resection) of the bulky infiltrative disease compared with superficial fulguration using the high-energy electrocautery or Argon beam coagulator. After that was completed, cholecystectomy was performed and the superficial deposit over the liver surface was ablated using electrocautery. At completion of that part, there was no gross disease left in the abdomen and an RO CRS was accomplished. The 5-mm right upper quadrant trocar site was extended for total length of 4 cm to allow retrieval of all resected specimens. The resected right upper quadrant peritoneum with underlying diaphragmatic fibers was retrieved as an intact of about 15×7 cm specimen, as shown in the video. Through this 4 cm incision, an extracorporeal, side-to-side, functional, end-to-end ileotransverse anastomosis was performed using a mechanical 3.5-mm linear stapler. At this point, we established the heated chemotherapy circuit with inflow catheter placed on the right upper quadrant over the liver and an outflow catheter on the left lower quadrant. Both catheters were placed through the 4 cm right upper quadrant incision that was temporally closed with a running stitch of 0 Nylon, as shown in the video. As per our protocol, 40 mg of mitomycin C was used for a total time of 90 minutes at 42°C. By the end of the 90 minutes, the heated chemotherapy was retrieved through the catheters, the abdominal viscera were washed using saline, and the right upper quadrant and trocar sites incision were closed. Total operative time was 380 minutes, and the estimated blood loss was 100 mL. The patient had uneventful postoperative period with no postoperative morbidity and was subsequently discharged on postoperative day 8. In conclusion, laparoscopic CRS-HIPEC is a relatively new approach for selected group of patients with peritoneal surface malignancy. The minimally invasive approach may offer an alternative to the traditional open approach in patients with multiple comorbidities. When indicated, the minimally invasive approach should be performed without compromising full abdominal exploration and should respect oncological principles, including the aiming for R0-CRS.

The video was presented during the 54th Society for Surgery of the Alimentary Tract (SSAT) annual meeting. Plenary session III.

No competing financial interests exist.

Run time of video: 6 mins 11 secs

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