Webinar Recap: Surgery for Peritoneal Mesothelioma

Our latest exclusive webinar, Surgery for Peritoneal Mesothelioma, gave patients and their families a chance to hear directly from leading experts in peritoneal surface malignancies. Surgical oncologists Dr. Laura Lambert and Dr. Zachary Brown of NYU Langone Health in Mineola, New York, joined board-certified Patient Advocate Karen Selby for a detailed conversation about surgical treatment options for peritoneal mesothelioma.

Together, they covered who may qualify for mesothelioma surgery and what the procedure involves. They also walked peritoneal mesothelioma patients and caregivers through what to expect from the first consultation through recovery at home. 

Our panelists gave patients and caregivers a clearer picture of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. They also explained how combining CRS with HIPEC works and why getting care at a specialized center matters so much. 

Who May Be a Surgical Candidate?

Dr. Lambert explained that several factors determine if someone qualifies for surgery. She noted the first thing surgeons look at is the histology, meaning what the cancer cells look like under a microscope. Peritoneal mesothelioma falls into a few categories: epithelioid, sarcomatoid, biphasic (a mix of epithelioid and sarcomatoid) and some rarer types like papillary mesothelioma. Each behaves differently and calls for a different treatment approach.Surgeons then review imaging like CAT scans to assess if they can safely remove all the cancer from the abdominal cavity. Dr. Lambert explained that if cancer has already spread outside the abdomen, the recommended treatment plan will likely change. Dr. Brown added: “The first thing is to do no harm.”

Questions Surgeons Address for Eligibility

• Cancer stage and location: Is the disease confined to the abdomen? How much of it is there, and can surgeons remove it all safely?
• Medical history: Does the person have heart disease, diabetes or other conditions that could raise surgical risk?
• Patient goals: What does the person hope to get from surgery and what does recovery realistically look like for them?
• Prior treatments: Has the person had chemotherapy or radiation? How much and how recently?

Dr. Lambert stressed that she and Dr. Brown want every patient and their family to feel confident going into surgery. “The last thing we want to do is take somebody to the operating room for a long surgery with high risks that really wasn’t comfortable with that decision,” she shared.

What Can Make Someone Ineligible?

Dr. Brown and Dr. Lambert use diagnostic laparoscopy to avoid a surprise finding during surgery of flat sheets of tumor on the small bowel that don’t show up on scans. Too many tumors on the small bowel generally means surgeons can’t safely remove it, which would mean the patient isn’t considered a surgical candidate.

Diagnostic laparoscopy is a minimally invasive procedure using tiny incisions with a camera. Surgeons look inside the abdomen before scheduling an invasive operation. Dr. Lambert noted: “Wouldn’t you rather have just an overnight stay than be cut from stem to stern to be told you’re not eligible?”

Sometimes patients stay overnight after diagnostic laparoscopy, but often they can go home the same day. Patients don’t need to stop chemotherapy and most get back to their routines within a couple of days. Surgeons can also take biopsies during the procedure to check for any new mutations that might point toward a different mesothelioma treatment.

Peritoneal Mesothelioma Surgery: What Are the Options?

Dr. Brown and Dr. Lambert walked through the main surgical procedures used to treat peritoneal mesothelioma. Karen Selby noted that while there isn’t yet a cure for mesothelioma, surgery can offer meaningful benefits for the right patients.

Peritoneal Mesothelioma Surgery Options

• Cytoreductive surgery: The gold standard surgery for peritoneal mesothelioma, surgeons remove all visible tumors. Dr. Brown noted it’s often several surgeries performed at once, targeting different areas of the abdomen at the same time.
• Diagnostic laparoscopy: Surgeons insert cameras to assess the extent of tumor growth and spread, often before major surgery to ensure tumor-removing surgery is possible.
• HIPEC: Surgeons deliver heated chemo directly into the belly after tumors are removed. This chemo wash typically circulates for 90 minutes. Dr. Lambert explained that heat makes chemo more effective and helps it penetrate deeper into tissue.
• Omentectomy: Surgeons remove a fold in the lining of the abdomen (the peritoneum) called the omentum. Cancer cells can develop there and it can interfere with HIPEC circulation, so surgeons often recommend an omenectomy.
• Paracentesis: A minimally invasive procedure, paracentesis drains fluid from the abdomen, which can build up and cause significant discomfort.
• Peritonectomy: Surgeons remove the peritoneum, the lining of the abdominal cavity. Dr. Brown performs a complete peritonectomy of the abdominal wall and pelvis for most people with peritoneal mesothelioma.

Dr. Brown explained why CRS and HIPEC work best together: “The cytoreductive surgery is really for the disease that you can see and the HIPEC is really for the disease that you can’t see.” HIPEC only penetrates a few millimeters into tissue, so it can’t treat large visible tumors on its own. Each treatment addresses different aspects of the disease.

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The Surgical Team and Cancer Center You Choose Matters

Dr. Brown and Dr. Lambert both emphasized that choosing where to have surgery is just as important as choosing a surgeon. Peritoneal mesothelioma is rare and the level of experience a center has with these operations directly affects outcomes.

At NYU Langone, a tumor board reviews every patient with peritoneal mesothelioma. Surgeons, medical oncologists, pathologists and radiologists meet together, review the case and plan the best approach as a team.

Karen added that post-operative nursing care plays a critical role in recovery from surgery. A team that regularly sees peritoneal mesothelioma patients knows what to watch for and how to respond. Dr. Brown encouraged patients to ask about the full support team at any center they consider, including intensivists, GI doctors and interventional radiologists, not just the surgeon performing the procedure.

What to Expect Before, During and After Surgery

The process begins well before a surgery date is even set, with the care team reviewing records and optimizing the patient’s health. For patients undergoing CRS with HIPEC, surgeons, nurses and the anesthesiology team work in close coordination across an operation that can span most of a day. Recovery is gradual but structured, with clear milestones guiding patients from the ICU to discharge and beyond.

Before Surgery

Before any surgical date gets set, the care team gathers all available records: pathology reports, imaging studies, prior treatment notes and lab work. Dr. Lambert said she and Dr. Brown review everything before they even meet with a patient so they can have a meaningful conversation about options. If surgery looks like the right path, patients may have a diagnostic laparoscopy first.

Dr. Lambert’s Preparation Advice

• Avoid smoking and limit alcohol in the weeks leading up to surgery.
• Eat enough protein to support healing. It can come from any source: fish, chicken, eggs or red meat.
• Get aerobic exercise. Walking, biking, swimming or any movement helps build the stamina needed for a major operation. “It’s like training for a marathon,” Dr. Lambert said.

One of the most common concerns during the waiting period is anxiety. Patients often worry that pausing chemo, which surgeons require before the operation to let blood counts recover, gives the cancer a chance to grow. Dr. Lambert said she’s rarely seen that happen. “If it did,” she said, “that would probably be a sign to us about the biology of that tumor. And honestly, the surgery probably wouldn’t be helpful.”

During Surgery

CRS with HIPEC is a long, complex operation. Dr. Brown said it typically runs 8 to 10 hours, with surgeons working through a midline incision from the chest to the lower abdomen.

Surgeons first explore the entire abdominal cavity to confirm the operation is feasible. Then they remove all visible tumors, along with any affected tissue nearby. Once that work is complete, the HIPEC process begins.

The HIPEC circulation runs for 90 minutes using a closed technique, with heated chemotherapy circulated through the abdomen via catheters connected to an external machine. The full HIPEC process takes about 2.5 hours from setup to completion.

Throughout the operation, the anesthesiology team continuously monitors heart, lung and brain function. Dr. Brown emphasized it’s a true team effort: “It’s a big coordination between the surgeons, the assistants, the nurses, the anesthesiology team and the folks on the floor.”

After Surgery

Most patients at NYU Langone go to the ICU immediately after surgery, not because they’re critically ill, but so the team can closely monitor vital signs, fluid levels and pain. Dr. Lambert said patients can typically expect a hospital stay of about 7 to 10 days.

Patients get up and moving the day after surgery. Walking helps stimulate the bowel, reduces the risk of pneumonia and helps prevent blood clots. Dr. Lambert outlined what patients need to accomplish before they can go home.

Dr. Lambert’s 5 Goals After Surgery

• Drinking enough to stay hydrated
• Eating a small amount of food
• Having a bowel movement
• Managing pain with medications they’ll take at home
• Feeling ready to leave

Dr. Lambert also warned patients to expect something on their first post-surgery scan: “The radiologist is going to see something. There’s going to be some kind of fluid or inflammation.” She reassures patients that this is normal after major surgery and that the first scan simply sets a new baseline.

Recovery at Home

Dr. Brown tells patients to expect a full recovery to take 2 to 3 months. Energy levels fluctuate. Some days feel like progress while others feel like a step back. Appetite may return slowly. Emotional challenges are also common and completely normal.

A strong support system at home makes a real difference. Caregivers can help with meals, transportation to follow-up appointments and day-to-day tasks while the patient heals. Dr. Brown encouraged patients to call their surgical team with any questions or concerns, no matter how small. “The only bad phone call is the one that’s not made,” he stressed.

Dr. Lambert closed with a reminder for patients not to rush themselves: “Be incredibly patient. It’s a lesson in patience. The recovery is not to be underestimated. Be kind to yourself.”

The Importance of a Second Opinion

Both Dr. Brown and Dr. Lambert encourage patients to seek a second opinion and not just from another surgeon. Dr. Brown said patients should also ask for another pathologist to review the diagnosis, since peritoneal mesothelioma comes in several subtypes that each require different treatment approaches.

“If surgery was ruled out too quickly, maybe see somebody else,” Dr. Brown noted. “The expertise really does vary.”

Neither doctor takes it personally when patients want another set of eyes on their case. Getting the diagnosis and the treatment plan right matters more than anything else.

What the Research Shows

Dr. Lambert said the volume of research on peritoneal mesothelioma treatment has grown significantly in recent years. She added that the field has gotten much better at selecting the right patients for surgery. 

Surgical techniques keep improving and treatments like immunotherapy are changing how surgeons sequence treatment. While immunotherapy isn’t yet FDA-approved for peritoneal mesothelioma, clinical trials focused specifically on peritoneal patients are now enrolling participants.

“Longer-term survival is becoming achievable in the right setting,” Dr. Lambert emphasized. “When we meet somebody, we’re looking to do everything that we can to help them be one of the people who achieves long-term survival with this disease.”