Chapters Transcript Video Cytoreductive Surgery & HIPEC Rod L. Flynn, M.D., presents a surgical case of a 41 year-old male with high grade goblet cell cancer of the appendix. The appendix had ruptured, so Dr. Flynn performed a cytoreductive procedure and hyperthermic intraperitoneal chemotherapy. Hello. I'm dr Rod Flynn and I'm a surgical oncologist at the Sentara care plex hospital. And today I'd like to discuss with you the care of a 41 year old gentleman with a history of appendices cancer that underwent a cider reductive procedure with high peck which stands for heated intra peritoneal chemotherapy. This patient is a robust 41 year old african american gentleman who had presented to Sentara Care plex hospital with right lower quadrant pain which he'd had for several days. A cat scan was performed which had the appearance of a ruptured appendicitis surgery was consulted and he underwent an urgent diagnostic laparoscopy and he had a laproscopic appendix removal at that time. The final results after the removal revealed what we call a high grade goblet cell cancer of the appendix. The patient then underwent systemic chemotherapy because it had ruptured and he was then referred to the peritoneal surface malignancy program here at the Sentara care plex hospital for further evaluation and treatment recommendations. He underwent a cider reductive surgery and high packed procedure which we will discuss further during this talk. So we're now beginning the procedure. So for this patient with the cancer of the appendix we have to do what's called the right collector. Me and the reason for that is because we have to do a lymph node harvest to make sure that the patient doesn't have any spread. Not just to his peritoneal cavity but also to the lymph nodes. So we've now opened the abdomen and we've put in this very fancy retractor which is very good because the goal is we want to achieve maximal exposure. We want to look at every square inch of this abdominal cavity for any little implants of cancer. What you're looking at there is the transverse colon and this is a greater momentum, which is a great nesting grounds for small cancer cells because of the there are a lot of theories as to why, but it basically is a nice nesting ground for stray cancer cells because of the blood supply as well as the lymphatic supply. So at this point, what we do is we expose every element of the abdominal cavity and we do what's called running the bowel. So we look at all of the intestines to make sure that there are no tumor implants or droplets that can come from a ruptured cancer. So at this point that greater momentum. The other terms we call that the policeman of the abdomen. Again, it's just a fatty apron that just drapes over the abdominal cavity and it walls off infections like of a ruptured appendix. That momentum kind of just lays in that area and helps to prevent it from disseminating this is now the greater momentum that has been taken out completely intact. And what we're doing there is looking for any gross evidence of tumor implants. Fortunately this patient didn't have that. So now what we're doing is we're preparing the large bowel or the colon for a resection again. Our goal is to do a write hemi, collect a me and right there, we're looking at the sick. Um And that's the base of the appendix. There was still a little stump of the appendix left which we take with the right collector me. We're looking at the ascending colon there and this is the transverse colon that yellow stuff in between is what we call the mesen terry. And that's where the middle colic or the blood supply to the colon lives. And so that was a middle colic artery we just saw. So here we're using a fancy stapler that both staples and cuts the bowel. And so now we're looking at the right collector me specimen that was removed. And so now we're irrigating the abdomen, making sure that everything is nice and dry that there's no blood loss. And so now we are uh splicing together the terminal ilium with the transverse colon there. And there are different ways of doing this old school, particularly for these high peck procedures. So I like to do a hand sewn good old fashioned hand sewn anastomosis. So we're doing a two layered hand zone uh re connection of the bow. There are some people that use staplers which is also equally as valid. But but for me in my hands doing a hand sewn stapling tech hand sewn anastomosis for this is the better way and I can sleep better at night. And how we're looking at the tubing for the perfusion. I just put together a one of the temperature probes, we attach those because we want to monitor the inflow temperature of this profusion setup. Now, what you're seeing is we're closing the skin over the inflow and outflow tubing that we use to the left. What you see is our device which is it's almost like a dialysis machine. And what we do is we connect inflow and outflow and then we start the profusion Where we infused up to three liters of sailing into the abdominal cavity and we get the temperature heated up to about 108°C. And now what you're seeing is we're instilling the first a lot of chemotherapy into the abdominal cavity. And now what we're doing is we're just distributing that chemotherapy throughout the abdominal cavities, the so called shake and bake. Part of the procedure that's done for 90 minutes. A total of 90 minutes after which we then open up the skin sutures and reopen the abdomen. At this point we inspect the abdominal cavity completely to make sure that there are no injury to the bowel, that there's no bleeding, that our anastomosis is intact. And then what we do is we suction out any residual fluid and again, just make sure all of our sponge counts are correct. Again, make sure there's no bleeding or anything else and then we go on to close the abdomen and that's what you're seeing right there. We do it in several layers to try to avoid any types of hernias. So this procedure, the average time I'd say, can be anywhere from 8 to 10 hours, depending on how much cancer is there. Sometimes it could go even longer. My longest is 17 hours. His postoperative course was relatively unremarkable and he was discharged from the hospital on post operative Day number six, tolerating a regular diet and having normal bowel movements. Published February 1, 2022 Created by Related Presenters Rod Flynn, M.D. Surgical Oncology View full profile