VM57 - Port Placement Concerns & Issues During Laparoscopy for Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC)

Purpose/Background: Pressurized Intrabdominal Aerosol Chemotherapy (PIPAC) is a novel method of delivering palliative chemotherapy in aerosol form directly to peritoneal metastases (PM) that is minimally invasive and can be repeated. A multi-armed American multicenter Phase 1 study has been underway for several years and has enrolled over 30 patients (colorectal, ovarian, gastric, and appendiceal primaries). Several ports are required to administer PIPAC and an exploratory laparoscopy is done prior to treatment. Port placement in PM patients can be very challenging due to thickened peritoneum, disease, adhesions, and prior intraperitoneal treatment. Bowel injuries in this population are associated with a very high morbidity and mortality. This video highlights the challenge of placing ports in PM patients and makes suggestions and tips regarding safe insertion.

Methods/Interventions: Many PIPAC treatments have been given to 40 enrolled patients (trial calls for 3 PIPAC treatments/patient) Case videos were reviewed in reference to port placement and demonstrative clips selected. The extent of difficulty encountered during placement was noted and the methods used in difficult cases noted.

Results/Outcomes: In fact, port placement in this population is challenging and gets harder with successive treatments due to scarring and chemotherapy related sclerotic changes in the parietal peritoneum. Penetrating the parietal peritoneum with the sharp trocar tip requires much vertical pressure and repeated torquing and twisting of the bladed trocar; these efforts bring the bowel and abdominal wall together and increase the chances of enterotomy. Angling the trocar tangentially (as parallel to the abdominal wall as possible) once the tip has penetrated the peritoneum reduces the chances of injury. Also, in very difficult cases, incising the fascia and peritoneum by vertically inserting a scalpel deeply and carefully into the abdominal wall can provide a lower resistance tract that the trocar can subsequently follow.

Conclusion/Discussion: Port placement is often very difficult in PM patients due to multiple factors. Extreme care need be taken when inserting the ports to avoid bowel injury that is difficult to repair in this population. Insuring against a sudden port thrust and assuming a flat insertion angle once the trocar tip has penetrated are suggested. Careful vertical trans-abdominal wall scalpel incision of the parietal peritoneum prior to trocar insertion can also facilitate placement. Realization that port insertion is the most dangerous aspect of PIPAC cases is important and will, hopefully, decrease the injury rate.