The procedure for the closed technique is demonstrated on the DVD. After induction of anesthesia, a urethral catheter with a heat-sensor probe is placed in the bladder (Precision 400; Tyco Healthcare Group, Mansfield, MA) and the anesthesiologist places an esophageal heat sensor (DeRoyal, Powell, TN). After the initial draping of the chest and legs, a large sterile IobanTM-2 adhesive drape (3M Corp., St. Paul, MN) (Fig. 4) is placed over the entire operative area, extending laterally beyond the anterior superior iliac spine, midaxillary line on each side. One hour before completion of surgery, the patient's core temperature is gradually lowered to about 34°C, as assessed by the bladder and esophageal probes, by turning the warming blanket off and lowering the air temperature in the operating room.
Upon completion of debulking surgery, the patient is readied for IP hyper-thermic chemotherapy. Two inflow tubes are placed, one above the right lobe of the liver with a temperature probe attached to the tip and the other in the left upper quadrant (Figs. 5 and 6).
Two outflow tubes are placed one on either side of the pelvic floor, with a temperature probe connected to the end of one (Figs. 7 and 8).
Before skin closure, the surgeon must ensure that the inflow and outflow tubes are correctly placed. The outflow tubing is laid at the back of the abdomen, behind the small bowel, and the single connecting tube is brought out in the upper abdomen (Fig. 9). The skin of the abdominal incision is closed using a free Richard-Allan 2090-1 3/8" needle connected to a 96" PDS #1 loop (Ethicon, Inc., Somerville, NJ) in a running, "baseball" fashion. Care is taken to ensure that the skin edges are not inverted and that the skin is tightly apposed around the tubing (Figs. 10 and 11).
Approximately 30 min before placement of the tubing, the perfusionist prepares the Thermochem™ HT-1000 modified heat-exchange pump (Thermaso-lutions, Inc., Pittsburgh, PA). With the wound closed, the inflow and outflow tubing is connected, and the preheated Deflex™ peritoneal dialysis solution (Fresenius Medical Care, Lexington, MA) is allowed to fill the cavity (Fig. 12).
While this is happening, the patient is placed in steep Trendelenberg to allow air to be expelled through the outflow tubing. Usually, 2-3 L is required to distend the cavity and achieve a flow rate of approximately 1,500 cc/min. The patient can be leveled once equilibrium is reached. When the temperature probes show a consistent inflow temperature of approximately 43°C and outflow of approximately 42°C (Fig. 13) the chemotherapy agent is added to the perfus-ate. The perfusion is allowed to circulate within the abdominal cavity for 90 min, with an assistant on each side of the patient gently kneading the abdomen to ensure good distribution. Care is taken to watch for leakages, and these are secured with sutures of 0 polyglactin 910 (Vicryl; Ethicon Inc., Somerville, NJ).
At the completion of perfusion, the perfusate is drained into the waste container attached to the Thermochem™ HT-1000 machine. The abdomen is carefully opened, with a disposable sump sucker at the ready to aspirate residual fluid. The abdomen and pelvis are gently irrigated with 2-3 L of saline to wash away any residual chemotherapy agent and avoid contamination during the remainder of the procedure. All contaminated instruments and tubing are passed off and placed in dangerous substance containers. Gowns and gloves are changed and the surgery is completed.
Postoperatively, patients are routinely followed in the Intensive Care Unit, and attempts made to maintain a urine output of at least 100 mL/hr for the first 72 hrs.
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