Ultrasound-guided preoperative progressive pneumoperitoneum to facilitate pressurized intraperitoneal aerosol chemotherapy in inoperable peritoneal carcinomatosis.

INTRODUCTION

Approximately 5% of patients with peritoneal carcinomatosis are excluded from pressurized intraperitoneal aerosol chemotherapy (PIPAC) due to a "non-accessible abdomen" caused by extensive adhesions. Preoperative progressive pneumoperitoneum (PPP) is traditionally used in complex hernia repair but has not been applied to facilitate PIPAC. This study evaluates the feasibility and safety of ultrasound-guided PPP to overcome this technical barrier.

MATERIALS AND

METHODS

A prospective study was conducted in five patients with histologically confirmed inoperable peritoneal carcinomatosis and a pre-established non-accessible abdomen. PPP was performed using controlled, intermittent air insufflation via a percutaneous catheter placed under ultrasound guidance with hydrodissection. Pre-PIPAC computed tomography confirmed adequate intra-abdominal volume for safe laparoscopic access. Primary outcomes were technical success (successful laparoscopic access and PIPAC delivery) and safety (complications and 30-day mortality).

RESULTS

The combined PPP-PIPAC approach achieved 100% technical and clinical success. All five patients underwent successful transformation of non-accessible abdomens to accessible ones, enabling safe laparoscopic PIPAC or electrostatic PIPAC (ePIPAC) delivery. No procedure-related complications or adverse events occurred during the 30-day post-procedure period. High clinical tolerability was observed across repeated treatment cycles.

CONCLUSION

Ultrasound-guided PPP with hydrodissection successfully transforms non-accessible abdomens into accessible ones, enabling safe PIPAC delivery in previously excluded patients. This novel, reproducible approach provides a practical solution to a common technical limitation in surgical oncology, potentially expanding treatment eligibility by approximately 5% for patients with peritoneal carcinomatosis.