Abdominal Exposure

• Abdominal cavity is opened through midline incision from xiphoid to pubis.
• Skin edges are secured by heavy sutures to the self-retaining retractor which allows elevation of the abdominal wall. Strong elevation of the abdominal wall reduces the risks of bowel injury especially when adhesions are anticipated.
• Generous abdominal exposure is achieved through use of Thompson Self-retaining Retractor.

Electrosurgical Setup

• 3-mm ball-tipped electrosurgical handpiece is the standard tool to perform electro-evaporative surgery.
• Electrosurgery is used on pure cut at high voltage.
• Benefits of electroevaporisation include: tumour destruction at margins and reduce risk of bleeding.
• Smoke extraction and filtration is used to preserve smoke free atmosphere.

1- Anterior parietal peritonectomy

• The peritoneum is dissected away from the posterior rectus sheath.
• Self-retaining retractor is steadily advanced along the anterior abdominal wall which optimises the broad traction at the point of peritoneal dissection.
• Peritoneum is most adherent where it directly overlies the transversus muscle.
• As the dissection proceeds beyond the peritoneum overlying the paracolic sulcus (line of Toldt), the dissection becomes much easier and tissues more loose.

2- Right subphrenic peritonectomy

• Peritoneum is stripped from beneath the right posterior rectus sheath
• Strong traction applied by the self-retaining retractor
• Ball-tipped electrosurgery is used to dissect the interface between peritoneum and underlying tissues.
• The peritoneum is placed under strong traction to elevate the rolled edge of the diaphragm.
• As the central tendon of the diaphragm is reached, blunt dissection with finger is possible with minimal blood loss.
• As dissection proceeds over the right side of the liver, the 12^th rib becomes palpable.
• Once the right hepatic vein is identified, electrosurgical dissection of the peritoneal reflection on the liver can be initiated to complete the resection of the right subphrenic peritoneum. The dissection proceeds from medial to lateral in anticlockwise direction.
• Areas of caution(avoid injury to):
  • Upper Medial: right hepatic vein
  • Lateral: right cardiac lobe veins and right adrenal glands
  • Lower medial: 2^nd portion of duodenum.

3- Left subphrenic peritonectomy

• Epigastric fat and peritoneum at the edge of the abdominal incision are stripped off the rectus sheath.
• Strong traction is exerted on the left subdiaphragmaticperitoneum to separate the tumour of the diaphragmatic muscles and the left adrenal gland.
• The splenic flexure of the colon is severed from the left abdominal gutter and moved medially by dividing the line Toldt.
• Dissection beneath the left hemidiaphragm muscle must be performed with ball-tipped electrosurgery and NOT blunt dissection.

4- Cholecystectomy, lesser omentectomy and omental bursectomy

• The gallbladder is removed in a routine fashion from its fundus toward the cystic artery and cystic duct, which are then ligated and divided.
• After dividing the peritoneal reflection onto the liver, the cancerous tissue that coats the porta hepatis is bluntly stripped using Russian from starting from the base of the gall bladder bed toward the duodenum.
• The right gastric artery is preserved.
• Use ball tipped electrosurgery to separate the tumour from the liver caudate with great care due to risk of excessive bleeding. Care must be taken to avoid injuring the left accessory liver artery.
• Use digital pressure to separate the tumour from the left & right gastric arteries along the lesser stomach curvature.
• Once the lesser omentum is removed you can access the omental bursa. Careful dissection using combination of electrosurgery and Russian forceps is used to separate the peritoneum with cancer.

5- Visceral sparing pelvic peritonectomy

• Peritoneum is resected from the pelvic side wall and bladder surface down the uterus.
• The uterine artery is ligated at the crossing point with the ureter. The uterus is resected and the anterior and posterior vaginal walls are transacted.
• An Allis clamp is placed on the posterior vaginal wall for traction.
• Peritoneum from the pararectal fossa, posterior aspect of the vagina and the middle 1/3 of the rectum removed enbloc as a “cul-de-sactomy”