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Peritoneum
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12
Surgical Procedure
Cytoreductive Surgery
5 Median laparotomy from the xyphoid
process to the symphysis pubica
5 Incision of the abdominal wall without
incision of the peritoneum, detachment
of the closed parietal peritoneum
5 Opening the peritoneum
5 Staging=documentation of the Perito-
neal Cancer Index (PCI) according to
Sugarbaker (a total of 13 regions to be
assessed)=prognostic factor and relevant for indication:
– Abdominal cavity divided into 9
regions
– Small intestine into further 4 regions
– Point system depending on tumor
size in each region: Absence of
tumor = 0 points (LS0); up to
0.5 cm = 1 point (LS1); up to
5cm=2 points (LS2); > 5cm=3
points (LS3)
– PCI between 0 and 39 points
(.
Fig.12.2)
5 Removal of all visible tumor manifes-
tations (up to multivisceral resection);
if a stoma is necessary: Only after
HIPEC
5 Postoperative classication: Complete-
ness of Cytoreduction (CC) according
to Sugarbaker (.
Fig.12.3)= prognostic
factor
5 Therapy goal=CC-0 or CC-1
5 Placement of 4 26-CH silicone drains
(= preparation HIPEC and drainage):
– One inow: At the site of greatest
tumor burden
– Three drains: Subphrenic right,
subphrenic left, Douglas…
– Two intra-abdominal temperature
probes
5 HIPEC:
– Following cytoreductive surgery
(.
Fig.12.1)
– Inow temperature 41–43 °C
– Perfusion time 30–120min
– Open or closed perfusion
– Chemotherapeutics
– At present, there is no uniform rec-
ommendation on the type and dose
of cytostatic drug to be used
123
8
7
. Fig. 12.2 Peritoneal carcinoid index according to Sugarbaker. (Mod. according to Jacquet and Sugarbaker 1996)
4
0
5
6
Regions:
0 Central
1 Right upper quadrant
2 Epigastrium
3 Left upper quadrant
4 Left ank
5 Left lower quadrant
6 Pelvis
7 Right lower quadrant
8 Right ank
9 Oral jejunum
10 aboral jejunum
11 Oral lleum
12 aboral ileum
PCI
Size of lesion:
Evaluation of the lesion's size:
LS 0 No visible tumor
LS 1 Tumor up to 0,5 cm
LS 2 Tumor up to 5,0 cm
LS 3 Tumour > 5.0 cm or conuen
11
12
9
10
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J. Pelz
CC-0 CC-1 CC-2 CC-3
No tumor Tumor remnants – 0.25 cm 0,25 – 2,5 cm > 2,5 cm
12
. Fig. 12.3 Completeness of Cytoreduction (CC
score) according to Sugarbaker. Assessment of postoperative tumor burden after cytoreductive surgery. Surgical score CC-0 means that no tumor was left; CC-1
Concept andGoals
5 Resection of the primary tumor
5 Macroscopic complete removal of all
accessible tumor metastases
5 HIPEC (= hyperthermic intraperitoneal
chemoperfusion)=destruction of remaining tumor cells after CRS
5 The value of hyperthermic perfusion is
unclear. Preliminary publications of the
PRODIGE-7 study do not show any survival benets with the use of oxaliplatin.
Indication
5 Limited tumor extension
5 Good general condition
5 No or<3 resectable distant metastases
5 Little evidence regarding the success of the
therapy
5 Few/old studies
5 Difcult comparability
5 Problems with patient selection
5 Tumor entities: (see overview)
Indications of CRS and HIPEC According
to Tumor Entities
5 Pseudomyxoma peritonei:
– Absolute indication for HIPEC
therapy=Highest level of evidence
– Ten-year survival rate of 69% after
CRS and HIPEC
– Low-grade tumor with signicantly
better outcome
tumor remnants up to 0.25cm, CC-2 tumor remnants of
0.25–2.5cm, CC-3 tumor remnants larger than 2.5cm.
(Mod. according to Jacquet and Sugarbaker 1996)
– Right hemicolectomy not recom-
mended for R0-resected low-grade
tumors
5 Colorectal cancer:
– Only one randomized trial (Ver-
waal etal. 2003)= signicant survival benet with respect to HIPEC
therapy
– Five-year survival = 54%; median
survival = 62 months in highly
selected patients (= benet for
patients likely linked with surgery)
– Careful patient selection=absolute
prerequisite!
5 Ovarian cancer:
– Systemic chemotherapy=currently
therapy of choice
– CRS + HIPEC currently under
investigation
– Controversial publications: tendency
to lack of benet for CRS+HIPEC
– Therefore no recommendations in
the current S3 guidelines
– Interdisciplinary approach needed
(gynaecologist + surgeon)
5 Mesothelioma:
– Difcult to treat tumor
– Men with signicantly worse out-
come
– Median (overall) sur-
vival=33months
– Better survival in epithelioid sub-
type and after CC-0 resection
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5 Stomach:
– Overall poor prognosis
– Systemic therapy = therapy of
choice
– Median survival=15months
– Perioperative lethality rate of 4.9%
– Contraindication for PCI>10 and/
or signet ring cell carcinoma
– Rather HIPEC in synchronous
peritoneal carcinomatosis (Gas-
tripec randomized trial)
5 Intra-abdominal sarcoma:
– Very poor prognosis despite multi-
modal therapy
– Median survival=26months
– Systemic chemotherapy = therapy
of choice
– Only in studies
5 Tumors of the hepatobiliary system:
– Very poor prognosis
– Systemic chemotherapy = therapy
of choice
– Only in studies
Risk-Benet Analysis
5 To be determined individually for each
patient
5 Interdisciplinary consideration in a tumor
board
5 No uniform standards for the indication
of CRS+HIPEC
5 Individual and interdisciplinary assess-
ment of risks: potential benet must be
higher than risk of complications
5 Caution: Delay of palliative systemic che-
motherapy
12.5.2 Prophylactic/Adjuvant CRS
andHIPEC
5 Theoretical approach
– Risk minimization of metachronous
peritoneal carcinomatosis
– Use in high-risk patients
5 The Prophylochip study failed to show any
benet in these patients
301
Indications
5 High-risk patients
5 T3/4 carcinomas with tumor rupture
5 Mucinous or signet-ring cell carcinoma
5 Isolated omental metastases/Krukenberg
tumors
Evidence
5 Currently no evidence
5 Some evidence for a signicant improve-
ment in tumor-free survival
5 No increase in complication rate due to
chemoperfusion
5 Randomized trial ongoing (prophylactic
HIPEC)
Learning Curve
5 Signicant reduction in morbidity and
lethality
12.5.3 Palliative Therapeutic
Concepts forAscites
5 Therapy of choice for ascites=paracentesis
5 Systemic chemotherapy = conditional
control of malignant ascites
5 HIPEC for ascites control (short-term
effect only)
12.5.4 Complications
5 With the use of CRS and HIPEC compli-
cation rate increases with the extent of
resection
5 Complication rate depends on the type
and dose of cytostatic drug used
Most Common Complications
5 Anastomotic insufciency (4.5–33%,
depending on author and tumor)
5 Fistula (3–6%)
5 Intra-abdominal abscess (10–17%)
5 Bleeding (1.5–12%)
5 Ileus (2–17%)
5 Wound healing disorders (2–15%)
5 Toxicity (20–26%)
5 Nephrotoxicity 16–19%
5 Haematotoxicity 14–20%
12
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J. Pelz
12
Strategies toMinimize
Complications
5 Patient selection
5 Learning curve
5 As few gastrointestinal anastomoses as
possible
5 Protective stomas should be generously
indicated (especially for anastomoses in
the rectal region)
5 Monitoring in the intensive care unit
5 Close monitoring of laboratory parame-
ters=obligatory (focus on blood count)
5 Postoperative chest X-ray in extended
peritonectomy of the diaphragm
5 Chemoperfusion always with a certied
perfusion device
5 Establishment of Centers of expertise
Learning Curve/Patient Selection
5 Learning curve: 100 procedures
required to:
– Reduction of complications
– Improvement of CC-0 resection
rate from 35.6% to 65.1%
– Reduction in morbidity from 71.2%
to 34.1%
– Reduction in the average length of
stay in hospital from 21 to 17days
– Reduction of the reoperation rate
from 30% to 10%.
– Planning and training
5 Patient selection by:
– Advanced imaging
– Interdisciplinary discussion (tumor
board)
– Individualized decision—by means
of e.g. Peritoneal Surface Disease
Severity Scores (PSDSS; Pelz etal.
2009)
– Lack of standardization of selec-
tion criteria for surgical therapy
(guidelines from the 2006 consensus conference in Milan)
12.5.5 Results
5 Signicant survival benet in selected
tumor entities
5 Optional situation in the current german
S3 guidelines for colorectal cancer
(. Fig.12.4)
5 High morbidity between 25% and 60%
5 Mortality between 2% and 10%
5 Quality of life:
– Postoperative: deterioration in the rst
days to weeks after surgery depending
on the size of the surgical intervention
and the peri- and postoperative complications
– Reaching the preoperative baseline
level: After about 3–4months
– In a proportion of patients: Long-term
improvement
12.5.6 PIPAC (Pressurized
Intraperitoneal Aerosol
Chemotherapy)
5 The PIPAC is a palliative therapy
5 Possibility of laparoscopic local therapy
5 Pure chemotherapy (no cytoreduction)
5 Repeatability of the therapy
5 Improvement of overall survival in selected
patient population
5 Still little valid data
12.5.7 Guidelines
AWMF Guideline “Colorectal Carcinoma”
7 https://www. awmf. org/uploads/tx_szleit
linien/021- 007OLk_S3_Kolorektales-Karzi
nom-KRK_2019- 01. pdf
AWMF Guidelines “Ovarian Cancer”
7 https://www. awmf. org/uploads/tx_szleit
linien/032- 035OLl_S3_Ovarialkarzinom_
2020- 04. pdf
Peritoneum
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. Fig. 12.4 Clinical
pathway using the
example of colon cancer
303
Colon carcinoma with peritoneal carcinomatosis
Diagnostics
Isolated peritoneal carcinomatosis Pronounced carcinomatosis
Surgical Exploration Systemic Therapy
CC-0/1 possible CC-0/1 not achievable
Cytoreduction+ HIPEC Palliative surgery only
Systemic therapy
12
References
Jacquet P, Sugarbaker PH. Clinical research methodolo-
gies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res.
1996;82:359–74. https://doi.org/10.1007/978-1-
4613-1247-5_23. PMID: 8849962.
Pelz JO, Stojadinovic A, Nissan A etal (2009) Evaluation
of a peritoneal surface disease severity score in
patients with colon cancer with peritoneal carcinomatosis. J Surg Oncol 99:9–15
Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW,
van Tinteren H, Boot H, Zoetmulder FA (2003)
Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic
chemotherapy and palliative surgery in patients
with peritoneal carcinomatosis of colorectal cancer.
J Clin Oncol 21:3737–3743. https://doi.org/10.1200/
JCO.2003.04.187
Suggested Reading
Baratti D, Kusamura S, Azmi N, Guaglio M, Montenovo
M, Deraco M (2020) Colorectal peritoneal metastases treated by perioperative systemic chemotherapy
and cytoreductive surgery with or without mitomycin C-based HIPEC: a comparative study using the
peritoneal surface disease severity score (PSDSS).
Ann Surg Oncol 27(1):98–106
Ceelen W (2019) HIPEC with oxaliplatin for colorectal
peritoneal metastasis: the end of the road? Eur J
Surg Oncol 45(3):400–402. https://doi.org/10.1016/j.
ejso.2018.10.542. Epub 2018 Oct 31
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Hernia
JensOtto, ThorstenLindenau, andKarstenJunge
Contents
13.1 Anatomy andClassication – 307
13.1.1 Hernia Anatomy – 307
13.1.2 Epidemiology – 307
13.1.3 Pathogenesis andClassication – 307
13.1.4 Hernia-Specic Complications – 308
13.2 General Diagnosis andTherapy Principles – 308
13.2.1 Diagnosis – 308
13.2.2 Therapy Principles – 308
13.3 Incisional Hernia – 308
13.3.1 Denition – 308
13.3.2 Incidence – 309
13.3.3 Aetiology – 309
13.3.4 Clinical Presentation – 309
13.3.5 Diagnosis – 309
13.3.6 Surgical Therapy – 309
13.3.7 Guidelines – 311
13
13.4 Inguinal andFemoral Hernia – 312
13.4.1 Anatomy, Denition andClassication – 312
13.4.2 Epidemiology – 312
13.4.3 Pathophysiology – 313
13.4.4 Clinical Presentation – 313
13.4.5 Diagnostic Procedures – 313
13.4.6 Therapeutic Principles – 313
13.4.7 Guidelines – 317
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
F. Billmann, T. Keck (eds.), Essentials of Visceral Surgery,
https://doi.org/10.1007/978-3-662-66735-4_13
13.5 Umbilical andEpigastric Hernia – 317
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13.5.1 Umbilical Hernia – 317
13.5.2 Epigastric Hernia – 317
13.5.3 Clinical presentation – 317
13.5.4 Diagnosis – 317
13.5.5 Therapy – 317
13.5.6 Guideline – 318
13.5.7 Dierential Diagnosis: Rectus Diastasis – 318
13.6 Parastomal Hernia – 318
13.6.1 Denition – 318
13.6.2 Epidemiology – 318
13.6.3 Risk Factors andPrevention – 318
13.6.4 Clinical Presentation – 319
13.6.5 Relevant Complications – 319
13.6.6 Therapy – 319
13.6.7 Guidelines – 320
13.7 Other Rare Hernias – 320
13.7.1 Spieghel’s Hernia (Hernia Lineae Semilunaris) – 320
13.7.2 Hernia Obturatoria – 320
13.7.3 Hernia Ischiadica – 320
13.7.4 Hernia Perinealis – 320
13.7.5 Lumbar Hernia – 320
References – 321
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13
13.1 Anatomy andClassication
13.1.1 Hernia Anatomy
5 Hernia gate
– Gap in the layers of the abdominal wall,
pelvic oor, diaphragm or back muscles.
5 Hernia sac
– Lining of the hernia; protrusion of the
parietal peritoneum.
5 Content of hernia sac
– All components of the abdominal cav-
ity possible.
13.1.2 Epidemiology
Hernia Incidence
5 In the normal population=2–4%.
5 In older age=up to 20.
5 10–15% of general surgery procedures.
Hernia Distribution
5 Proportion of external hernias=95.
– Inguinal hernias (75%).
– Scar hernias (10%).
– Umbilical hernias, thigh hernias and
rare forms of hernia (5–7% each).
5 Proportion of internal hernias=5.
13.1.3 Pathogenesis
andClassication
Pathogenesis
5 Preformed or secondary fascia gap.
5 Development of the hernia = protrusion
of the parietal peritoneum through the
gap.
Hernia Classication
5 According to position relative to the
abdominal wall (. Table13.1):
. Table 13.1 Classication of hernias
according to position in relation to the abdominal wall
External hernias Internal hernias
Inguinal hernia
(inguinal hernia)
Direct
Indirect
Femoral hernia
(thigh hernia)
Umbilical hernia
(umbilical hernia)
Paraumbilical
hernia
Epigastric hernia Hernia at the mesentery
Incisional hernia
(also parastomal
hernia)
Spieghel hernia
(linea semilunaris)
Rare hernias
Bochdalek
Grynfelt
Trigonum
lumbale (petit)
Treitz hernia
Paracoecal hernia
Hernia through foramen
omentale (Winslowi)
Hernia at the mesosigma
(postoperative mesoslit),
Petersen hernia
Pelvic oor peritoneal
hernia
Paravesical hernia
– External hernias: Protrusion of the
peritoneum through the abdominal wall
“outwards” (e.g. inguinal hernias).
– Internal hernia: Hernia within the
abdominal cavity, no external appearance (e.g. ileocecal hernias).
5 According to clinical aspects:
– Reponible/Irreponible: hernial contents
to be forced back into abdominal cavity
(or not).
– Incarcerated: Non-reducible, acutely
painful protrusion (incarceration).
5 By etiology:
– Congenital hernia (e.g. open processus
vaginalis peritonei in indirect inguinal
hernia).
– Acquired hernia (e.g. incisional hernia).
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J. Otto et al.
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13.1.4 Hernia-Specic
Complications
Intestinal Incarceration
5 Most common complication.
5 Emergency situation
5 Clinical presentation:.
– Severe pain, palpable, bulging elastic
tumor, local environmental irritation,
irreducibility, vomiting, ileus, intestinal
perforation, peritonitis.
5 Caution: The sun must neither rise nor set
over a pinched hernia (OP within max.
12h).
Hernia
5 Danger of spontaneous perforation.
5 Clinical presentation: swelling, redness,
hyperthermia, painfulness.
Mains Clamping
5 Clinical presentation: Pressure painful,
non-responsive hernia with little impairment of the patient.
13.2 General Diagnosis
andTherapy Principles
13.2.1 Diagnosis
Further Investigations
5 MRI or CT.
5 Only in the case of corresponding symp-
toms, complex situation (recurrent nd-
ings) or poor assessability (e.g. obesity).
13.2.2 Therapy Principles
5 In the case of acute incarceration=man-
ual reduction of the fracture tumour only
within the rst few hours.
! Caution
Bowel perforation/reposition of gangrenous
bowel with delayed attempt at reduction.
5 Successful reduction=inpatient monitor-
ing + surgical repair of the hernial gap
during the same stay.
5 Unsuccessful reduction = operation as
soon as possible + vitality check of the
content of hernia sac.
Procedure forSurgical Therapy
5 Direct fascia suture/fascia doubling:
Shouldice, Bassini.
5 Sublay mesh implantation.
5 Combination methods.
5 Laparoscopic procedures: e.g. TAPP
(transabdominal preperitoneal plasty),
TEP (total extraperitoneal plasty).
Physical Examination
5 Palpation of the hernial gap.
5 Palpate contents of hernia sac if
necessary.
5 Assessment of reproducibility.
5 In the case of irreducible hernias, differen-
tiation between chronic irreducibility (e.g.
in the case of adhesion or excessive extent
of the hernia) vs. acutely occurring irreducibility=incarceration.
Sonography
5 Most important tool for assessing fracture
aperture, fracture content and size indication.
13.3 Incisional Hernia
13.3.1 Denition
5 Post-operative fascia defects in the area of
a fascia scar.
5 Hernial gap/hernia sac (7 Sect. 13.1).
Distinction: Incisional hernia – rectus diastasis – burst
abdomen:
5 Differentiation by hernial gap and hernia sac.
5 Rectus diastasis: widening of the linea alba with
divergence of the rectus muscles.
5 Abdominal laceration: early postoperative abdomi-
nal wound dehiscence after laparotomy.
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13
13.3.2 Incidence
5 Most frequent postoperative complica-
tion.
5 Up to 18%, depending on the investigation
period.
5 In Germany: 100,000 incisional hernias
per 700,000 laparotomies per year; only
30% of hernias with surgical treatment.
5 Longitudinal laparotomies more affected
than transverse laparotomies.
13.3.3 Aetiology
5 Impaired scar formation due to impaired
collagen metabolism (congenital/
acquired).
5 Multifactorial risk prole.
5 Risk factors s. Overview:
Risk Factors for Incisional Hernias
5 Patient-related:
– Age (>45years).
– Male gender.
– Obesity (BMI>25).
– Ascites.
– COPD (chronic obstructive pulmo-
nary disease).
– Consuming disease.
– Diabetes mellitus.
– Renal failure.
– Anemia (Hb<10g/dL).
– Nicotine abuse.
– Chemotherapy.
– Steroid therapy.
– Collagen metabolism disorder.
5 Surgical:
– Recurrent surgery.
– Emergency surgery.
– Contaminated surgical eld.
– Experience of the surgeon.
– Fascia suture technique Prevention
through small bites– technique.
– Thread material.
5 Postoperative condition:
– Wound infection.
5 In the search for the risk prole for the development
of incisional hernias, the multifactorial genesis is
always emphasized.
5 Aim for etiological treatment (before surgical therapy
or in parallel).
13.3.4 Clinical Presentation
5 Mostly asymptomatic.
5 Noticeable only by increase in size.
5 Advancement of peritoneal organs; risk =
“loss of domain”.
5 Entrapment symptoms (e.g., irreducibility,
pain, passenger disruption): Up to 15.
– With intestinal strangulation: Up to 2%.
13.3.5 Diagnosis
Clinical Examination
5 Examination always lying down + stand-
ing (+ pressing).
5 Clinical signs 7 Sect. 13.3.4.
Sonography
5 Standard procedure.
5 Conrmation of diagnosis + exclusion of
a complication.
5 Extent of the hernia gap (planning of the
operation).
CT or MRI
5 In case of unclear ndings.
5 For complex recurrence ndings with
implanted mesh materials.
5 With pronounced obesity.
13.3.6 Surgical Therapy
Operation Indication:
5 Every incisional hernia=indication for surgery.
5 If incarceration is suspected=emergency.
Open Procedures
Suture Procedure
5 Direct suture of the fascia gap
5 Only indicated for small trocar hernias
with unclear initial occlusion
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