Introduction

The treatment of peritoneal surface malignancies requires comprehensive management that utilizes maximal cytoreductive surgery (CRS) and intraperioperative hyperthermic chemotherapy (HIPEC) [1]. One of these procedures is the total pelvic peritonectomy which is performed to completely remove the disease from the pelvic peritoneum [2]. This procedure has a high rate of morbidity and mortality, uses large laparotomies, and results in prolonged hospital stays [3]. The laparoscopic peritonectomy procedures and HIPEC have been evaluated as feasible and safe in highly selected patients with low PCI in low grade [4, 5] and high grade diseases [6]. Complete laparoscopic pelvic peritonectomy (LPP) through natural orifice extraction and HIPEC have been reported by our institution [7, 8]. The aim of this study is to present a detailed description of this technique, including the analysis of the first 12 cases performed in the two referral centers in Spain (Cordoba and Madrid).

Materials and methods

We conducted a study on consecutive patients who had LPP + HIPEC for limited peritoneal carcinomatosis (PCI < 10) from January 2017 to November 2019 at 2 referral centers in Spain.

Patient selection

The inclusion criteria were: (a) patients diagnosed with peritoneal carcinomatosis from ovarian cancer, colon cancer and benign multicystic mesothelioma with limited disease (PCI < 10), (b) no previous major surgeries and (c) no presence of huge intra-abdominal masses that could not be managed by a laparoscopic approach. A diagnosis of limited disease confined to the pelvis and some implants in the omentum could be included for a minimally invasive approach as discussed in an earlier publication [7]. All the patients provided informed consent and the ethics committee approved the study.

The LPP procedure

The patient is placed in the lithotomy position and a uterine manipulator is inserted. The trocars are placed according to the surgery requirements, with five ports being the most usual, three at 12 mm and two at 5 mm (Fig. 1).

Fig. 1
figure 1

Trocar placement

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The complete abdominal cavity, pelvis, and the entire mesentery, omentum, lesser omentum, diaphragms, hepatic hilum, retrohepatic and retrosplenic spaces must be explored exhaustively to calculate the PCI and the feasibility of a complete cytoreduction by laparoscopic approach. To do that, the complete mobility of the operating table and a 30 or 45° camera should be used.

The pelvic peritoneum is removed centripetally as described by Sugarbaker et al. [2] (Fig. 2). The left and right parietal peritonectomies are performed by dissecting the peritoneum and retroperitoneal space up to the iliac vessels. Both ureters are dissected and the ovarian vessels and round uterine ligaments are divided. From lateral to medial, the dissection continues from the bladder peritoneum to the anterior wall of the vagina, filling the bladder with saline solution to facilitate the dissection. Both uterine vessels are divided over the ureter to completely remove the parametrium bilaterally. The division of the vagina leads to the rectovaginal space to completely remove the pouch of Douglas. The specimen includes the bilateral parietal and pelvic peritoneum, uterus and adnexa, which are extracted through the vagina using a laparoscopic bag. Depending on the case, a bilateral iliac lymphadenectomy may be performed. Appendectomy and total omentectomy are performed. All specimens are extracted through the vagina which is then closed with a running barbed suture.

Fig. 2
figure 2

(Courtesy of Ref. [2])

Scheme of open pelvic peritonectomy with or without sparing of the rectum.

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After a complete cytoreduction (Fig. 3) the tubes for the HIPEC administration are placed through the laparoscopic ports. As shown in the image, two tubes are used for in-flow and two tubes are used for out-flow. A transparent device is placed in the umbilical port to measure the intrabdominal level of chemotherapeutic solution during the HIPEC (Fig. 4).

Fig. 3
figure 3

Laparoscopic complete pelvic cytoreduction

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Fig. 4
figure 4

Tube placement for HIPEC administration by laparoscopic approach. A transparent trocar is allocated to check the intraperitoneal level of solution

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Results

Twelve LPP + HIPEC were performed at the two institutions. The features of the patients, the origin of the tumour and type of chemotherapy administered have been summarized in Table 1. Two cases had major morbidity (Clavien–Dindo: IIIa) as one patient had a hernia in the left port that required minor surgery and the other patient had a pleural effusion (after a diaphragmatic peritonectomy) that required a pleural drainage. No HIPEC toxicities were described. There was no mortality. The median length of hospital stay was 5.5 [4,5,6,7,8,9,10] days. The median length of follow-up was 10 months (range 2–30 months).There was no early (> 12 months) locoregional recurrence. One patient (primary ovarian carcinomatosis) had a local relapse in the splenic hilum at 18 months post-CRS and HIPEC that was removed by laparoscopic splenectomy and the patient is currently is cancer-free. All the patients are alive at the time of this study. The patient outcomes are summarized in Table 2.

Table 1 Patients who underwent total laparoscopic pelvic peritonectomy and omentectomy
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Table 2 Patient outcomes
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Discussion

Total en bloc parieto-pelvic peritonectomy associated with total omentectomy plus HIPEC is a complex procedure used to remove all macroscopic disease in the context of peritoneal carcinomatosis [2, 3]. The open approach means performing an extended laparotomy which results in prolonged postoperative hospital stays and recovery. A minimally invasive approach can minimize the surgical aggression and improve patient recovery [6]. To or knowledge this is the first video of this procedure focusing specifically on complete pelvic peritonectomy via a laparoscopic approach. [9]. Pelvic peritonectomy may be associated or not with a pelvic and peri-aortic lymphadenectomy depending on the type of tumors [10]. The laparoscopic approach allows us to perform this procedure in case we need it, however, this video is not focused on lymphadenectomy procedures.

The experience in laparoscopic cytoreductive surgery and HIPEC is still limited, although some reports have shown its feasibility, reporting similar efficacy and safety using this technique when compared to the open approach. This minimally invasive approach should be reserved for patients with limited peritoneal dissemination, with a PCI of 10 or less [6.] The benefits reported with a minimally invasive approach include less wound morbidity and length of hospital stay allowing for quicker recovery while reducing the wait time for chemotherapy [7]. As this study shows, hospital stays averaged about 5 days with a median wait time for chemotherapy of 2 weeks.

The treatment of colorectal carcinomatosis with CRS and HIPEC has been established worldwide with a cumulative experience that shows an improvement in the survival of this group of patients [11]. It has been shown (in the PRODIGE 7 trial) that the use of high dose oxaliplatin for only 30 min does not improve survival compared to CRS alone [12]. In our study, we used mitomycin C for the HIPEC procedure for colorectal and pseudomyxoma peritonei origin. Mitomycin C has showed good results [13]. Our group, like many groups, continues to use mitomycin C. Even the groups that used oxaliplatin have changed to mitomycin C. It is true that we need a randomized controlled trial to demonstrate the effect of mitomycin C itself associated with complete cytoreductive surgery.

The recurrence and survival rates reported in our study compare favourably to those reported by other authors utilizing the open approach for cytoreductive surgery and HIPEC, with no early recurrence identified. The recurrent disease diagnosed in our cohort was excised using a laparoscopic approach and at the time of reporting this study, all patients are living.

One of the most important limitations of the laparoscopic CRS + HIPEC is the difficulty of performing a thorough exploration of the entire abdomen and pelvis to determine a true PCI. Some areas are difficult to explore such as the retrohepatic and retrosplenic spaces and the entire mesentery, thereby requiring the use of a 30° or 45° optical or flexible optical to access these areas.

We present the first technical video of a minimally invasive approach for a complex Sugarbaker procedure as a total pelvic peritonectomy [2]. This is beneficial for highly selected patients as it results in improved recovery which allows them to return to chemotherapy sooner [14] but it is likely that morbidity is due to the extent of resection and that conclusions regarding the benefits cannot be drawn until results of long- term analysis are available. We might, in future, establish that this approach is safe and feasible, but we need longer follow-up periods to compare oncologic outcomes.