Achieving complete cytoreductive surgery (CRS) of peritoneal metastasis requires a specific operative strategy. As a specific organ, the peritoneum requires specific surgical skills. Because a majority of CRSs are performed with a midline incision, liver mobilization is specific and mandatory to control small tumor implants that could be close to the vena cava. Diaphragm resection must be limited and treated with suture but must include prosthesis if extended. Spleen mobilization is necessary and could be complex, depending on patient body weight and tumor implants. Just like spleen resection, left-angle colonic mobilization could induce pancreatic damage, requiring a control strategy. Douglas pouch resection without rectum resection should be well known because it decreases sequelae compared with proctectomy. In contrast, pelvic resection could be necessary with the first peritoneal resection and secondary uterus and after rectal resection to obtain a complete pelvic CRS. Specific details are available regarding the operative procedure specifically devoted to peritoneal surgery. In case of prior colonic resection, rectal resection could induce major colonic resection, which could necessitate ileo-anal anastomosis. Reconstruction after ureteral resection favors reimplantation with uretero-neocystostomy. If the ureter is associated with bladder resection, an uretero-ileal anastomosis could be necessary. Collaboration with urologists can help to control the morbidity rate associated with intraperitoneal chemotherapy. In case of abdominal wall resection, using a biological mesh could be valuable as a bridge procedure to avoid parietal extensive surgery that could increase postoperative complications and to avoid any synthetic mesh that could increase tumor progression by tumor implantation.
