Cytoreductive surgery and HIPEC is one of the most complex abdominal surgeries often called the ‘mother of all surgeries’ given its extensive nature, risk of complications and its impact on the physiological and psychological well being of the patient leading to a prolonged recovery period compared to other procedures.

What is peritoneal cancer?

Any cancer that  spread predominantly to the peritoneum or arises primarily from the peritoneum is called peritoneal cancer. It is characterized by the presence of cancer cells on the peritoneum which is the lining of the abdominal cavity and the organs that it contains like the liver spleen and the intestines.

Commonly, cancers of the ovary, colorectum (large intestine), stomach and appendix spread to the peritoneum. There are some other rare cancers like pseudomyxoma peritonei and mesothelioma which commonly affect the peritoneum.

Peritoneal cancer is stage 4 cancer

What is the treatment of peritoneal cancer?

Peritoneal cancer is traditionally treated with systemic chemotherapy till recent times. Currently evidence is emerging for a  radical surgical approach called cytoreductive surgery (CRS)  and HIPEC- hyperthermic intraperitoneal chemotherapy  to treat patients with peritoneal cancer resulting in a prolonged survival and even cure in some patients

What is HIPEC?

HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy. In this procedure, a solution containing a chemotherapeautic agent in circulated in the abdominal cavity at a high temperature of arround 40 to 42 degree centigrade for a period of 30-90 mins using a dedicated pump or machine.

Is HIPEC a surgery?

 HIPEC is not a surgery but a procedure done in addition to the surgical procedure . During surgery,  all the visible tumor and some of the potentially  involved areas are removed first ,  which is called Cytoreductive Surgery (CRS) and then the  heated solution containing the anti cancer drug (chemotherapy drug) is circulated in the abdominal cavity .It is persumed that  this process destroys microscopic tumors and tumors of 1-2mm size as well.

How many sessions are needed?

 HIPEC is a single procedure done during surgery.  Occasionally patients can undergo a second HIPEC if the cancer recurs.

 What is Cytoreductive surgery? 

Cytoreductive surgery comprises of removal of tumor from the peritoneal /abdominal cavity. The aim of this surgery is to remove all the visible tumor and also remove some of  the potential sites of tumor spread. To achieve this the peritoneum that has tumor is stripped off the abdominal wall and from the organ surfaces. Sometimes a part of the small or large intestine, gall bladder, liver, spleen, stomach or pancreas may also have to be removed to achieve complete removal of the tumor. This is a extremely important as the outcome depends on the completeness of the procedure. Completeness of  tumor removal depends on the expertise of the surgeon and also the extent of tumor itself.  

Is HIPEC a high risk surgery?

Cytoreductive surgery and HIPEC is a very complicated surgery and the risk of complications is a little high as compared to other cancer surgeries. After a HIPEC, complications occur in about 15- 20% of patients. It also carries a mortality of 3 to 5 % even in best of centres.

Is HIPEC worth the risk?

Cytoreductive surgery and HIPEC is the only treatment which can sometimes cure certain patients with peritoneal cancer and significantly prolong the life of others . Hence, patients with peritoneal cancer should have a specialist consultation to explore the options of various treatment options. Proper tackling of complications and mobidity help patients get back to their normal life. The risk is minimized when an experienced  team performs the procedure. There are certain conditions like patients with appendix cancer and pseudomyxoma peritonei, mesothelioma, and selected patients of colorectal, ovarian and gastric cancer . There is a  benefit for cytoreductive surgery and  HIPEC and is worth the risk.  The decision needs to be individualized and the surgeon should clearly explain to the patient and family the risk versus benefit of the procedure.

Who should be performing these procedures ?

Centres with  dedicated team performing these procedures routinely are preferable . It is said the team experience of 100 to120 cases will help in better outcomes in these advanced malignancies.The team comprises of surgeon, anaesthetist , intensivist, and other supportive staffs. The experience and expertise of the team helps in better surgical outcomes in terms of completeness of tutor removal, minimize complications and also helps in rescuing the patient from life threatening complications .

HIPEC – role played by the family

In India, the patient’s family plays an integral role in the decision making process for any kind of cancer treatment and is vital in providing after care to the patient. Family members provide a strong support system filling in for the paramedical and medical staff at various time points in the treatment

Decision making

It is not uncommon for family members to not reveal the diagnosis of cancer to the patient till long after the treatment has been completed. However, this is not the right thing to do for a patient undergoing CRS and HIPEC . It is important that one or more counseling sessions are held with the patient and the family and they fully understand what the surgery entails- the potential benefits and risk. The patient needs to be mentally prepared for a longer than usual post operative stay and the prolonged recovery period thereafter.

Preparing for the procedure

Patients often have to travel to another city to obtain treatment since the required expertise may not be available in their own city or country. This means one or more family members having to take at least 2-3 weeks off from work. Once the patient returns home, after care in needed in the form of supporting the patient’s day to day activities, providing frequent nourishing meals among other things. Hence, the care-givers need to plan their time off from work accordingly.

Managing finances

In India the cost of HIPEC procedure ranges from 3-5 times that of a surgery for resection of a routine cancer surgery. This may represent a substantial financial burden especially for those who have had multiple prior treatments and have exhausted their resources and/or insurance; it is an out-of-pocket expenditure for many Indian patients. The same needs to be discussed and planned. CRS and HIPEC may be followed by other therapies like systemic chemotherapy in a large proportion of the cases

Psycho-social impact

The patient may take 6-12 weeks to regain his/her strength and well-being and the immediate family / spouse/ children have to be extremely supportive during this period. Depression and pyschosis are not uncommon and family support is vital in overcoming these. There is fear about the long term impact of such a treatment especially in young patients who are just starting their careers and family life. Patient’s quality of life may also be influenced by a temporary or permanent digestive stoma.

Child bearing after HIPEC

With careful prior planning having children after CRS and HIPEC is possible in selected patients, both male and female. These issues should be brought out prior to the procedure and treatment planned accordingly.

Survivorship and long term outcomes

There is apprehension in the minds of both the patient and the family about tumor recurrence and many times they avoid coming for a follow-up regular follow ups are needed. Many patients undergo a second procedure for tumor recurrence. This is the only treatment that can cure some patients, add few extra years to the lives of others and provide a better quality of life, and keeping these benefits in mind, patients and families should approach the procedure with confidence  to derive the maximum benefit from it.


About the author:


Dr. Dileep Damodaran MBBS, MS, DNB (Gen. Surgery), MCh (Surg. Oncology) is a surgical oncologist working with Malabar Institute of Medical sciences, Kozhikode