In a crowded operating room deep inside St. Agnes Hospital on June 3, Dr. Jesùs Esquivel carefully sliced cancer tissue from a patient's appendix and out of his abdomen.

Paying careful attention to Esquivel and his surgical team were several military doctors, a videographer from the Department of Defense, a hospital spokesman and members of the media -- all wearing surgical scrubs, masks and plastic eye covers.

The surgery was part of a week-long training seminar sponsored by the Department of Defense for eight military doctors to learn about a rare cancer treatment that Esquivel, of Clarksville, has been performing since 1998.

The procedure, which is performed in only about 25 hospitals across the country, according to Esquivel, is called cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, or HIPEC.

Bear Stevenson, 68, had come to the Caton Avenue hospital all the way from Roseville, Calif., to have it done.

The military doctors had come from all over the country.

"This is a very complicated, complex, demanding procedure, and we're here to understand the relevant factors," said one of the observers in the room, Dr. Len Henry, of the National Naval Medical Center in Bethesda.

"We're looking to learn as much as we can," he said.

Others who came to train with Esquivel during the week were Jeff Lenert, also of the National Naval Medical Center; Alex Stojadinovic of the Walter Reed Army Medical Center in Washington; Scott Steele and Tommy Brown of the Madigan Army Medical Center in Tacoma, Wash.; Cletus Arciero and Eric Johnson of the Dwight D. Eisenhower Army Medical Center in Augusta, Ga.; and Matthew Hueman, of Johns Hopkins School of Medicine and a former Walter Reed surgeon.

First performed in 1980 but not popularized until the late-1990s, the procedure is a complicated process that takes hours.

Last week, Esquivel -- a nationally renowned expert in the procedure and director of St. Agnes' peritoneal surface malignancy program -- first removed all the cancer tissue he could see.

Then, two tubes and two wire temperature sensors were placed in Stevenson's abdomen, which was then stitched closed.

The abdominal cavity -- which is naturally separated from the rest of the body and the blood stream by what is called a peritoneal-plasma barrier -- was then flooded with three liters of heated, highly-potent liquid chemotherapy.

The fluid was constantly circulated in and out of Stevenson's body and kept at 107-degrees Fahrenheit by a machine called a Thermochem HT.

According to Esquivel, the fact that the chemotherapy can be pumped directly into the abdomen without having to go through the patient's intravenous system makes it much more effective.

"We're able to achieve a concentration that is 50 to 100 times more powerful than (when given) intravenously," he said.

Heating the chemotherapy allows it to target porous cancer cells as opposed to normal cells, he said.

"Normal cells have a self-defense mechanism and a larger blood supply to auto-regulate their temperature," Esquivel said. "Cancer cells have a limited blood supply."

Once Stevenson's abdomen was full of the circulating chemotherapy, Esquivel's advance surgical physician assistant, Allison Pitroff, prodded her fists against the swollen belly.

The surgical team's certified registered nurse anesthetist, Kathy Crowley, monitored Stevenson's vital signs.

Pitroff continued that grueling motion, sometimes resting one hand or another but rarely breaking contact, for the next 90 minutes.

Her rocking fists ensured the chemotherapy sloshed throughout Stevenson's abdomen -- "to take care of any cancer cells that are floating around in there that you haven't identified," said Pitroff, who was intricately involved in the surgical procedure throughout.

It also ensured that heat didn't build up in one area.

After Pitroff completed the prodding, she and Esquivel -- aided by operating room technician Carol Payne, registered nurse Karen Kogler and another certified registered nurse anesthetist, Wendy Weaver -- opened Stevenson's abdomen again and sopped up the remaining chemotherapy and saline dialysis fluid.

They stitched together the parts of Stevenson's anatomy that they had opened during the surgery -- "reconnecting the plumbing," Pitroff said -- and closed him up.

The entire procedure took about four hours, though it normally takes about seven, Esquivel said.

"We did everything we planned to do, so that's it," Esquivel said afterward. "That's always a good day."

During the procedure, an iPod pumped music throughout the room.

The casual, but competent, precision of Esquivel and his team "makes it look easy," Henry said.

"This is definitely not easy," he said.

For Esquivel, the chance to show more doctors how to perform the procedure is crucial because there are too few doctors performing it, he said.

That means patients must travel farther than they should. Esquivel's average patient travels more than 700 miles to St. Agnes and stays for an average of two weeks, he said.

"This patient had to come all the way from California," said Esquivel of Stevenson, who gave his approval for his surgery to be observed and documented.

"I think, in the near future, there will be an opportunity to have more centers (performing the procedure) across the country," Esquivel said.

While the procedure is often used to target appendix cancer, Esquivel said, "we think the real future for this type of procedure is colon cancer."

About 3,000 people are diagnosed with appendix cancer nationally each year, compared with some 150,000 diagnosed with colon cancer, Esquivel said -- hence the need for more doctors to perform the procedure.

Henry said he couldn't predict whether the training would lead to more military doctors performing the still-rare procedure.

But Esquivel said he is hopeful that will be the case.

"That's why these military surgeons are here," he said.

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