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Ray et al. J Cancer Metastasis Treat 2020;6:9 I http://dx.doi.org/10.20517/2394-4722.2020.16 Page 3 of 9

Figure 1. Peritonectomy using multiple artery forceps for retraction

Figure 2. Diaphragmatic peritonectomy with full-thickness resection of diaphragmatic deposits

in all cases. Selective peritonectomy was performed in the region(s) macroscopically affected by the tumor.
Total peritonectomy was performed in two cases in the present study, which had gross peritoneal disease.
Total peritoneal stripping in continuity is a technically demanding procedure, hence in the current study,
we followed the split technique, which involves stripping and removal of the entire peritoneum in five parts
- right subdiaphragmatic peritoneum along with Glisson’s capsule, left sub-diaphragmatic peritoneum, right
and left parietal wall/paracolic gutter peritoneum and pelvic peritoneum. Peritonectomy was performed by
holding and lifting the peritoneal edges with multiple artery forceps [Figure 1].

Surgical dissection was performed using monopolar diathermy with a sharp tip and diathermy settings at
30 coagulation spray mode although many surgeons prefer ball tip diathermy in pure cut mode. Additional
visceral organ resection (colectomy, colo-proctectomy, splenectomy, gastrectomy, appendicectomy,
cholecystectomy, liver resection and small bowel resection) may be performed, depending upon
involvement. Whenever bowel resection is required, we prefer resection-anastomosis before HIPEC. Bowel
edema, erythema and other hyperthermic chemotherapy-induced changes due to HIPEC at the edges of
the bowel wall may become a constant threat for anastomotic leaks. For diaphragmatic peritonectomy,
access and exposure of the diaphragmatic peritoneum were of utmost importance. Adequate exposure
was obtained with the Omni-Tract surgical retractor and the liver was completely mobilized, except at the
area of the hepatic veins and the suprahepatic inferior vena cava. For full-thickness large solid deposits
involving the diaphragm, we performed full thickness diaphragmatic resection in two cases of the present
study. In another case, partial resection of the hemidiaphragm was created for HITAC. Full-thickness
resection of the diaphragm and the subsequent diaphragmatic rent created are shown in Figure 2. Pleural
nodules were excised through the same rent in one case. The other two cases had only pleural effusion with
no pre-operative or intra-operative evidence of metastatic pleural deposits. Total parietal pleurectomy was