HIPEC
HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY

HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy. It is a two-phase procedure performed in a single operating room session — first, the surgical removal of all visible tumour deposits in the abdomen (cytoreductive surgery, or CRS), followed immediately by the perfusion of heated chemotherapy through the open or closed abdominal cavity.

“HIPEC is not a chemotherapy infusion in the traditional sense. It is a surgical operation with chemotherapy as the second act — a fundamentally different kind of treatment that requires fundamentally different planning.”

• Phase 1: Cytoreductive Surgery (CRS)

  The surgeon performs an extensive exploration of the abdominal cavity and removes all visible tumour deposits — often including peritoneal stripping, omentectomy, and resection of any organs affected by tumour. The goal is complete cytoreduction (CC-0) or near-complete (CC-1), leaving no tumour deposit larger than 2.5 mm.

• Phase 2: Heated Chemotherapy Perfusion

  Chemotherapy solution heated to 41–43°C is circulated through the abdominal cavity for 60–90 minutes. The heat amplifies the chemotherapy's cell-killing effect (chemosensitisation) while the direct cavity delivery achieves drug concentrations 10–100× higher than systemic administration — without systemic toxicity.

HIPEC is not appropriate for every patient with peritoneal cancer. Careful selection — based on disease extent, performance status, and the ability to achieve complete cytoreduction — is the single most important predictor of outcome.

• Disease Confined to the Peritoneal Cavity

  Candidates must have cancer limited to the peritoneal surfaces — no liver metastases, no lung metastases, no distant disease. Once cancer has spread beyond the peritoneum, HIPEC cannot reach it and the trade-off of major surgery is no longer justified.

• Peritoneal Cancer Index (PCI) Within Threshold

  The PCI is a 0–39 score quantifying how much tumour is present in 13 abdominal regions. Lower PCI predicts better outcomes. Cut-offs vary by cancer type: PCI <20 for colorectal, <28 for ovarian, and often higher acceptable thresholds for pseudomyxoma peritonei or mesothelioma.

• Complete Cytoreduction Is Technically Achievable

  The decisive factor is whether the surgeon can remove all visible disease to CC-0 (no residual) or CC-1 (≤2.5 mm residual). If preoperative imaging or intraoperative findings show this will not be possible, HIPEC is typically aborted — incomplete cytoreduction with HIPEC has no proven benefit.

• Good Performance Status and Organ Function

  Patients need ECOG performance status 0–1, adequate cardiac function (often ejection fraction >50%), normal renal and liver function, and acceptable nutritional status (albumin >3.0 g/dL). The procedure is physically demanding and recovery requires meaningful physiological reserve.

• Age and Comorbidities Within Limits

  There is no absolute age cut-off, but most centres limit HIPEC to patients under 75 with no major cardiopulmonary disease, no severe diabetes, and no significant immunosuppression. Frailty assessment, not chronological age, is the modern selection criterion at experienced centres.

• Cancer Type Has Recognised HIPEC Evidence

  Strongest indications are pseudomyxoma peritonei and peritoneal mesothelioma. Moderate-evidence indications include selected ovarian and colorectal peritoneal disease. Some gastric and sarcomatous peritoneal disease may be candidates in specialist programmes. Patients with cancer types lacking evidence are typically directed toward systemic therapy or clinical trials instead.

The strength of evidence and the role of HIPEC varies significantly by cancer type. Below is a clinical reference of the main indications.

A complete CRS + HIPEC operation typically takes 8–14 hours and is performed by a specialist surgical oncology team. Here is the sequence of events in a single OR session.

1. 1

   Step 1: Surgical Exploration and Staging

   Through a midline incision from xiphoid to pubis, the surgeon explores the entire abdominal cavity, calculates the intraoperative PCI score, and confirms that complete cytoreduction is achievable. If disease is too extensive or extra-peritoneal, the procedure may be aborted before further intervention.

2. 2

   Step 2: Cytoreductive Surgery

   All visible tumour is removed using a combination of peritonectomy procedures (Sugarbaker technique), omentectomy, splenectomy, and resection of involved bowel or other organs as needed. The goal is CC-0 or CC-1 status — complete or near-complete cytoreduction.

3. 3

   Step 3: HIPEC Perfusion

   Inflow and outflow catheters are placed in the abdominal cavity along with temperature probes. Chemotherapy solution heated to 41–43°C is circulated continuously for 60–90 minutes. The choice of drug, dose, and duration depends on the primary cancer type and centre protocol.

4. 4

   Step 4: Anastomoses and Closure

   After the chemotherapy is drained and the abdomen is irrigated, any bowel resections are reconstructed with anastomoses (most surgeons prefer to delay these until after HIPEC to avoid heated chemotherapy exposure to fresh staple/suture lines). The abdomen is closed.

5. 5

   Step 5: Intensive Care Recovery

   Patients are typically transferred to ICU for 1–3 days for haemodynamic monitoring and pain management, followed by a regular surgical ward stay of 7–14 days. Full recovery to baseline activity takes 2–4 months. Adjuvant systemic chemotherapy may be planned for selected cancer types.

Headline outcomes from the major phase III trials of CRS + HIPEC across the main indications.

For appropriately selected patients, HIPEC offers outcomes that systemic therapy cannot match. But the procedure is among the most demanding in surgical oncology, and the trade-offs are real.

Explore the full hyperthermia knowledge base and related cancer treatment pages.

Frequently Asked Questions

Common questions from patients, caregivers, and clinicians about HIPEC and CRS + HIPEC.