The catheter is tunneled above the fascia from an implantable port location, at the midclavicular line on the inferior costal margin, to a peritoneal entrance point approximately 6 cm lateral to the umbilicus. A tunneling device, which is packaged with the catheter, is ideal for this part of the procedure because it leaves a dissection tract only the width of the catheter. The catheter should be placed over the ascending or descending colon and progress toward the pelvis, depending on where the fewest adhesions are expected to form (Figs. 1 and 2). The catheter should be left long (10 cm-15 cm), so that it will not retract into the subcutaneous tissues (Fig. 3). If the catheter is placed in the upper abdomen, it may become trapped in adhesions that can develop between the liver and the diaphragm after peritoneal stripping, or between the transverse colon and the anterior abdominal
From: Current Clinical Oncology: Intraperitoneal Cancer Therapy Edited by: C. W. Helm and R. P. Edwards © 2007 Humana Press Inc., Totowa, NJ
wall after omentectomy. The catheter should drape into an area of intact peritoneal surfaces, which are less likely to form adhesions. The port pocket is created cephalad to a transverse incision along the lower costal margin in the midclavicular line. The port is sutured with 2-0 polypropylene (Prolene®; Ethicon, Inc., Somerville, NJ) in four corners to prevent future displacement and rotation, which impair Huber needle access into port lumen. The perforation into the peritoneal cavity must be kept as small as possible to prevent ascites or IP chemotherapy fluid from flowing retrograde into the subcutaneous tissues and port pocket. The vagina and the abdominal wall incisions must be closed watertight, with care to avoid leakage of ascites or chemotherapy fluid out of either wound. Care must also be taken not to tangle the catheter into the wound-closure suture. The subcutaneous tissue is closed over the port with 3-0 polyglactin 310 (Vicryl®; Ethicon, Inc.) and the skin is closed with subcuticular 4-0 polyglactin 310 (Vicryl® Ethicon Inc, Somerville, NJ) or 4-0 poliglecaprone (Monocryl®; Ethicon, Inc.) (Fig. 4). The port is accessed with a Huber needle, and the port and the catheter are flushed with 100 U/cc heparinized saline to document flow and maintenance of a patent lumen. This flushing procedure is repeated after each port access procedure for chemotherapy administration.
Controversy continues as to whether the use of adhesion barrier material should be advocated between the bowel and the abdominal wall to improve IP
chemotherapy fluid distribution. This issue requires further study, and there are many competing products on the market today. Some surgeons are currently placing routine adhesion barriers under the abdominal wound closure, whereas others use these products on other surfaces where the peritoneum has been removed.
The avoidance of foreign body placement at the time of peritoneal cavity contamination with fecal contents is based on good clinical judgment with limited evidence. There is evidence that patients are less likely to receive full-dose IP chemotherapy when the left colon is resected, but many of the patients studied never received their first cycle. Failures were often described as being caused by adhesions and complications of surgery. It is common practice to delay insertion of the IP catheter until a few days before the planned IP chemotherapy treatment. This allows further evaluation of the patient for surgical complications, such as peritonitis and anastomotic leak. The patient's recovery of bowel function after bowel resection and tolerance of a regular diet are reassuring and decrease the concern for infection and complications with IP chemotherapy. Delayed placement of an IP port may result in failure to place the device at all, due to lack of enthusiasm of the patient and/or physician for a second surgical procedure so soon after the first.
Delayed insertion of an IP access device can be accomplished by the following three techniques: minilaparotomy, laparoscopy in the operating room, and interventional radiology using percutaneous methods in the radiology suite. Our preferred method is similar to the aforementioned open laparotomy technique. Access to the peritoneal cavity is made in a region where adhesions are not expected. The right lower quadrant is the preferred location, if the terminal ileum and cecum were not resected. The incision should be several centimeters below and lateral to the umbilicus to avoid the adhesions of the transverse colon to the anterior abdominal wall, which occur after omentectomy. The peritoneal cavity is identified, and free space (without bowel adhesions) must be found for safe introduction of the catheter. The technique can be adapted to the surgeon's preference; the catheter can be tunneled down from the port pocket above the costal margin before being placed into the peritoneal cavity under direct visualization using the tunneling device, or it can be brought up from the peritoneal cavity into the subcutaneous tissues and tunneled to the port pocket. The catheter is brought through the peritoneum, muscle, and fascia with a tunneling device or tonsil clamp to keep the perforation as small as the catheter. The catheter should NOT go through the minilaparotomy incision—the incision is only meant to guide the catheter without bowel injury through the abdominal wall. The incision should be closed to avoid kinking the catheter, and each layer should be separately closed carefully to prevent leakage of ascites or IP chemotherapy fluid. The port is sutured with 2-0 polypropylene in four corners to the fascia overlying the lower ribs. The port pocket is closed in two layers, subcutaneous and dermis, to minimize erosion of the port through the skin. The scar of the wound should not be immediately over the port access site. The port is flushed with 10 cc-20 cc of heparinized saline (100 units/cc). The remainder of the procedure is similar to that described. Chemotherapy administration is delayed at least 24 h.
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