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1296 Technique of Intraperitoneal Chemotherapy: Normothermic and Hyperthermic

Figure 3. Plain X-ray showing retraction of catheter with coiling needle and flushed with 10ml of 100U/cc of heparinized
close to the port. saline to sure that the system is open and without leakage.
The wound is irrigated with saline and the skin incision
a gradient which might reduce the chance of retraction. is closed with staples or a subcuticular suture such as 4/0
The catheter should always be handled with care avoiding poliglecaprone (Monocryl®; Ethicon, Inc., Somerville,
the use of instruments with ‘teeth’ or sharp edges. The NJ, USA). The healed incision scar is shown in Figure 2D.
cephalad end of the catheter is attached to the port (if
not using a pre-attached port) and the port is tied down B) Delayed Placement: OPEN
using the previously placed sutures. The slack in the The patient is given general anesthesia and placed supine
catheter is taken up by pulling on the peritoneal end and on the operating table. Depending on the patient’s habitus
the catheter tip is cut at right angles to leave at least 12cm a 6cm incision is made roughly centered on the line
within the PC directed towards, but not deep within the between the anterior superior iliac spine and umbilicus
pelvis. If possible it should be placed away from denuded lateral to the rectus sheath (the right side is preferred
peritoneum and Seprafilm® (Genzyme, Cambridge, MA, if left colonic or rectal resection has been performed at
USA) may be placed adjacently to discourage adhesion the recent laparotomy). It is sensible to have placed an
formation. Since retraction of the port has been reported adhesion barrier at initial surgery under the areas that
(15) (Figure 3) a securing 3/0 polyglactin 310 suture might be later used for peritoneal access including, left
(Vicryl®; Ethicon, Inc Somerville, NJ, USA) may be upper quadrant, beneath the midline incision and both
placed around the catheter on the peritoneal entry point. iliac fossae. The external oblique fascia is opened in a
The port should be accessed using a 19-22 gauge Huber caudal and medial direction. The bellies of the internal
oblique and transversus muscles are split rather than
cut and the peritoneum is opened carefully in case of
underlying adhesions. The likelihood of this is reduced
by the previous application of an anti-adhesion barrier
such as Seprafilm® (Genzyme Inc., Cambridge, MA,
USA). Local adhesions can be divided and the peritoneal
space opened up. The port placement is carried out as
previously described. The TD can be tunneled down
from the port incision and advanced into the PC outside
of the open incision which can then be closed in layers
(16) or the TD can be disconnected at the level of the
wound and the catheter passed into the PC directly
through the wound. Following which the peritoneum
is closed with ‘0’ polyglactin 310 (Vicryl®; Ethicon, Inc
Somerville, NJ, USA) from lateral to medial and the EO
fascia from medial to lateral. The skin is closed with
staples or subcuticular suture such as 4/0 poliglecaprone
(Monocryl®; Ethicon, Inc., Somerville, NJ, USA).

C) Delayed placement: LAPAROSCOPIC
The patient is given general anesthesia and placed supine
on the operating table. The site and method of entry to

Table 2. Timing of Port Placement

Timing Method Advantage Disadvantage
Immediate Potential increased risk of infection
At the time of Single surgery Patient may not go on to receive IP therapy

cytoreductive surgery and port placed unnecessarily
Second procedure under GA
Delayed Open Adhesiolysis (limited)
Laparoscopic Reduced infection Second procedure under GA

Radiologic Adhesiolysis (extensive) No visualization of local or distant adhesions
Reduced infection No adhesiolysis
Smaller incisions

Placed in radiologic suite