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1302 Technique of Intraperitoneal Chemotherapy: Normothermic and Hyperthermic
Table 7. Comparison of Open and Closed Methods of Delivering HIPEC
Increased abdominal pressure
Potential for continued surgery during HIPEC
Potential for aerosol contamination
Distribution of chemotherapy and heat
Pharmacokinetic monitoring of tumor and normal tissues
Simultaneous perfusion of pleural cavity
Management of technical problems with intraabdominal tubing
Detection and treatment of occult bowel perforation
Adapted from (44)
HIPEC pumping equipment. Anti-emetics including 5
HT-3 receptor antagonists, dexamethasone and newer
agents like fosaprepitant are commonly administered IV
prior to the chemotherapy.
There are two major methods of HIPEC delivery: that
involving closure of the abdominal skin incision prior to
perfusion, the ‘closed method’ or that involving perfusion
with the wound open, the ‘open method’ sometimes
called the ‘coliseum’ method. A tabulated comparison
of these approaches is given in Table 7. ‘Semi-closed’
and laparoscopic methods have also been described
(43, 44). Animal (porcine) studies suggest that better
intraperitoneal drug concentration and pharmacokinetics
are obtained with the laparoscopic>open> closed method
(45, 46).
Whichever method is used, once perfusion is
completed, perfusate is allowed to drain off into a waste
container. The abdomen is opened completely and
residual fluid is carefully aspirated or removed with sterile in steep head-down position to facilitate the evacuation
towels. The abdomen and pelvis can be irrigated with 2-3
liters of saline to wash away any residual chemotherapy
agent. All contaminated instruments and tubing are
then passed off and placed in toxic substance containers.
Gowns and gloves are changed and the surgery, including
performance of anastomoses, is completed. Post-
operatively, patients may be monitored in the Intensive
Care Unit. If cisplatin has been used a urine output of at
least 100ml/hour should be maintained for the first 72
hours. Intra-operative and post operative monitoring of
electrolytes and coagulation parameters is necessary.
Closed Technique
Once CRS is complete two inflow tubes (one with a
temperature sensor attached at the tip) are connected by
a Y-connector to a single inflow tube (IT), and placed
above the right lobe of the liver and in the left upper
quadrant. Two outflow tubes (one with a temperature
Open Closed
No Yes
Yes No
Yes Less
Uniform throughout Variable
Yes No
Yes No
Easy May require opening of the
Easier abdominal incision
More difficult -have to
discontinue HIPEC to fix
sensor attached) are placed one on either side of the
pelvic floor and connected by another Y-connector to a
single outflow tube (OT). A temperature sensor may also
be secured by a suture to the peritoneum close to the root
of the small bowel mesentery. The outflow tubing is laid
at the back of the abdomen behind the small bowel and
the OT is brought out in the upper part of the incision
with the IT coming out of the lower part of the incision.
The skin (not the rectus fascia) of the abdominal
incision is closed using a long monofilament suture such
as polydioxanone sulfate (PDS) #1 suture (Ethicon Inc,
Somerville, NJ) in a running and locking fashion (Figure
6A). Care is taken to ensure that the skin edges are not
inverted and that the skin is tightly apposed around
the tubing. With the wound closed, the IT and OT are
connected to the heat exchange pump (Figure 6B,C)
and the pre-heated perfusate such as Deflex™ peritoneal
dialysis solution (Fresenius Medical Care, Lexington,
MA, USA), is allowed to fill the cavity with the patient
of free air. Between 2 and 3 liters is normally required
to distend the cavity. The operating table can be leveled
after the air is evacuated. When consistent desired inflow
and outflow temperatures (41-43°C inflow and 41-42°C
outflow) and flow rate (1000-1500ml/min) are achieved
the chemotherapy drug(s) is added to the perfusate. The
chemotherapy perfusate is allowed to circulate within
the abdominal cavity for 30-90mins while distribution is
assisted with gentle kneading of the abdomen from both
sides. Care is taken to watch for leaks through the skin
and these are secured with sutures such as 0 polyglactin
910 (Vicryl®, Ethicon Inc, Somerville, NJ).
Open Technique
The open technique is commonly referred to as the
“Coliseum technique” (47) (Figure 7). After the cancer
resection is complete, an IT is passed through a stab