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Peritoneum

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299

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

5cm=2 points (LS2); > 5cm=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 classication: 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 inow: 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)

– Inow temperature 41–43 °C – Perfusion time 30–120min – 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

. Fig. 12.2 Peritoneal carcinoid index according to Sugarbaker. (Mod. according to Jacquet and Sugarbaker 1996)

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 conuen

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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

. 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 andGoals

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 benets 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 Difcult 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 signicantly

better outcome

tumor remnants up to 0.25cm, CC-2 tumor remnants of

0.25–2.5cm, CC-3 tumor remnants larger than 2.5cm. (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 etal. 2003)= signicant survival benet with respect to HIPEC therapy

– Five-year survival = 54%; median

survival = 62 months in highly selected patients (= benet 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 benet for CRS+HIPEC

– Therefore no recommendations in

the current S3 guidelines

– Interdisciplinary approach needed

(gynaecologist + surgeon)

5 Mesothelioma:

– Difcult to treat tumor – Men with signicantly worse out-

come

– Median (overall) sur-

vival=33months

– 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=15months – 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=26months – 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-Benet 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 benet must be higher than risk of complications

5 Caution: Delay of palliative systemic che-

motherapy

12.5.2 Prophylactic/Adjuvant CRS

andHIPEC

5 Theoretical approach

– Risk minimization of metachronous

peritoneal carcinomatosis

– Use in high-risk patients

5 The Prophylochip study failed to show any

benet 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 signicant improve-

ment in tumor-free survival

5 No increase in complication rate due to

chemoperfusion

5 Randomized trial ongoing (prophylactic

HIPEC)

Learning Curve

5 Signicant reduction in morbidity and

lethality

12.5.3 Palliative Therapeutic

Concepts forAscites

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 insufciency (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%

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J. Pelz

Strategies toMinimize 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 certied

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 17days

– 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 etal.

2009)

– Lack of standardization of selec-

tion criteria for surgical therapy (guidelines from the 2006 consensus conference in Milan)

12.5.5 Results

5 Signicant survival benet 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 3–4months

– 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

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 etal (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

JensOtto, ThorstenLindenau, andKarstenJunge

Contents

13.1 Anatomy andClassication – 307

13.1.1 Hernia Anatomy – 307

13.1.2 Epidemiology – 307

13.1.3 Pathogenesis andClassication – 307

13.1.4 Hernia-Specic Complications – 308

13.2 General Diagnosis andTherapy Principles – 308

13.2.1 Diagnosis – 308

13.2.2 Therapy Principles – 308

13.3 Incisional Hernia – 308

13.3.1 Denition – 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

13.4 Inguinal andFemoral Hernia – 312

13.4.1 Anatomy, Denition andClassication – 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

https://doi.org/10.1007/978-3-662-66735-4_13

13.5 Umbilical andEpigastric 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 Dierential Diagnosis: Rectus Diastasis – 318

13.6 Parastomal Hernia – 318

13.6.1 Denition – 318

13.6.2 Epidemiology – 318

13.6.3 Risk Factors andPrevention – 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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307

13.1 Anatomy andClassication

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

andClassication

Pathogenesis

5 Preformed or secondary fascia gap. 5 Development of the hernia = protrusion

of the parietal peritoneum through the gap.

Hernia Classication

5 According to position relative to the

abdominal wall (. Table13.1):

. Table 13.1 Classication 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.

13.1.4 Hernia-Specic

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. 12h).

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

andTherapy 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 forSurgical 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 Denition

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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309

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 prole. 5 Risk factors s. Overview:

Risk Factors for Incisional Hernias

5 Patient-related:

– Age (>45years). – Male gender. – Obesity (BMI>25). – Ascites. – COPD (chronic obstructive pulmo-

nary disease). – Consuming disease. – Diabetes mellitus. – Renal failure. – Anemia (Hb<10g/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 prole 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 Conrmation 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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