What HIPEC Actually Involves — The Two-Step Procedure

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HIPEC is not a single procedure. It is two procedures performed sequentially in the same operating session, typically over 8 to 14 hours. Understanding both components — what each one does, why each one is necessary, and why neither is effective without the other — is essential for any patient evaluating this option.

Part 1 — Cytoreductive surgery

Cytoreductive surgery — also called debulking surgery or CRS — is the surgical removal of all visible tumour deposits from the peritoneal surface. The peritoneum is an extensive membrane: it covers the inner surface of the abdominal wall, the front of the spine, and the surfaces of every abdominal organ. Cancer deposits on the peritoneum can occur anywhere on this surface, which means cytoreductive surgery can involve stripping tumour from the inner abdominal wall, removing portions of the bowel, removing all or part of the omentum (the fatty apron hanging from the stomach), removing the spleen, removing part of the liver surface, and removing the appendix or portions of the diaphragm.

The goal is completeness. The standard against which cytoreductive surgery is assessed is the Completeness of Cytoreduction — CC — score. CC-0 means no visible residual tumour after surgery. CC-1 means residual nodules of 2.5 millimetres or less. CC-2 and CC-3 indicate progressively larger residual deposits. The survival benefit of HIPEC is almost entirely confined to patients who achieve CC-0 or CC-1 cytoreduction. Patients who achieve only CC-2 or CC-3 cytoreduction do not benefit significantly from adding the HIPEC component, and the major operative risk has been incurred for minimal gain. This is why patient selection is so important — and why the preoperative PCI estimation matters so much.

The extent of cytoreductive surgery varies widely between patients. For a patient with a PCI of 8 with three discrete deposits on the parietal peritoneum, cytoreduction might involve stripping those three areas and take 2 hours. For a patient with a PCI of 18 with widespread small deposits on the bowel mesentery, small bowel serosa, diaphragm, and pelvic peritoneum, cytoreduction might involve multiple bowel resections, peritonectomy of several regions, and 7 hours of operative time before the HIPEC component even begins.

Part 2 — The HIPEC wash

After cytoreduction is complete and all visible tumour has been removed, the abdomen is washed clean with saline. Drainage tubes — inflow and outflow — are positioned in the abdomen and connected to a closed perfusion circuit with a pump and a heat exchanger. The chemotherapy drugs — most commonly oxaliplatin for colorectal peritoneal metastases, mitomycin C for other indications — are mixed with saline in the circuit and heated to 41 to 43 degrees Celsius. The heated solution is then pumped into the abdomen and circulated continuously for 30 to 90 minutes while the surgeon gently moves the abdominal contents to ensure even distribution of the chemotherapy throughout the peritoneal cavity.

Why heat? Two reasons. First, heat directly kills cancer cells above 41 degrees Celsius through protein denaturation. Second, hyperthermia increases the penetration depth of chemotherapy drugs into tissue — heated oxaliplatin penetrates approximately 3 to 4 millimetres into the peritoneal tissue, compared to 1 to 2 millimetres at body temperature. This enhanced penetration is the mechanism by which HIPEC addresses the microscopic deposits that cytoreductive surgery cannot remove visually.

The blood-peritoneal barrier limits the amount of chemotherapy that enters the systemic circulation during HIPEC, which is why the systemic side effects of HIPEC are much milder than those of equivalent doses given intravenously. After the HIPEC wash is complete, the solution is drained, the abdomen is washed again with clean saline, and the bowel is reconstructed — anastomoses are created where bowel was resected — before abdominal closure.

Who Is a HIPEC Candidate — The Peritoneal Cancer Index Explained

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HIPEC is not appropriate for every patient with peritoneal metastases. The selection criteria exist because HIPEC is a major operation — one of the largest in gastrointestinal surgery — and performing it in patients who are unlikely to achieve complete cytoreduction exposes them to significant operative risk for minimal benefit. The formal selection process involves several assessments, of which the Peritoneal Cancer Index is the most important.

The Peritoneal Cancer Index

The Peritoneal Cancer Index divides the abdomen into 13 anatomical regions — nine abdominal regions based on a grid pattern, plus four small bowel regions. Each region receives a lesion size score from 0 to 3: 0 means no tumour seen, 1 means the largest deposit is under 0.5 centimetres, 2 means the largest deposit is 0.5 to 5 centimetres, and 3 means the largest deposit is above 5 centimetres or deposits are confluent and cannot be counted individually. The scores from all 13 regions are added to produce the PCI, with a maximum possible score of 39.

The PCI threshold for HIPEC candidacy is not a fixed number — it is a range that depends on disease distribution and the surgeon's assessment of resectability. As a general principle: PCI below 20 in a fit patient with disease in resectable locations is a candidate for HIPEC with curative intent. PCI 20 to 25 represents a grey zone where individual assessment is essential. PCI above 25 is associated with inability to achieve complete cytoreduction in most patients, and the procedure is unlikely to produce meaningful benefit — systemic chemotherapy is a better option.

Importantly, PCI score is not the only selection criterion. Where in the abdomen the deposits are matters as much as how many there are. Extensive involvement of the small bowel mesentery — the root of the mesentery where the small bowel's blood supply enters — is a particularly adverse factor because resecting this area is not feasible without sacrificing the entire small bowel. A patient with a PCI of 16 but concentrated in the small bowel mesentery may not be resectable, while a patient with a PCI of 22 with deposits primarily on the parietal peritoneum may achieve complete cytoreduction.

PCI score	Typical resectability	HIPEC recommendation	Expected outcome
Below 10	High chance of CC-0	Strongly consider HIPEC	Best outcomes — 5yr survival up to 30%
10 to 20	Good chance of CC-0/CC-1	HIPEC candidate	Median OS 30–45 months with complete CRS
20 to 25	Variable — depends on distribution	Individual assessment essential	Benefit if complete CRS achievable
Above 25	Complete CRS unlikely	HIPEC not recommended	Systemic chemotherapy is better option

Sources: Sugarbaker PH (Journal of Surgical Oncology 1995) · Glehen et al. (Annals of Surgery 2004) · Elias et al. (Annals of Surgery 2010) · NCCN Colon Cancer Guidelines 2025

Other selection criteria beyond PCI

No distant metastases beyond the peritoneum (or limited, resectable liver metastases in selected patients). If the cancer has spread to the liver, lungs, or other distant organs in addition to the peritoneum, HIPEC is unlikely to produce meaningful benefit as systemic disease will determine survival regardless of peritoneal control.

Good performance status. HIPEC is an 8 to 14 hour operation followed by ICU care. Patients need adequate cardiac, pulmonary, and renal reserve to withstand this physiological stress and recover. Patients with significant comorbidities — advanced cardiac disease, chronic kidney disease, or poor nutritional status — may not be surgical candidates regardless of their PCI score.

Favourable molecular profile. Patients with certain molecular characteristics — particularly BRAF V600E mutation — have significantly worse outcomes after HIPEC than patients with BRAF wild-type disease. The molecular profile does not absolutely disqualify a patient but influences the risk-benefit analysis and the likelihood that the disease will respond to the intraperitoneal chemotherapy used during HIPEC.

The PRODIGE 7 Trial — What It Changed and What It Did Not

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Any honest guide to HIPEC must discuss the PRODIGE 7 trial. It is the most important evidence about HIPEC for colorectal peritoneal metastases ever published, and its results were more nuanced — and more contested — than most HIPEC advocates are comfortable acknowledging.

PRODIGE 7 was a French multicentre randomised controlled trial published in the New England Journal of Medicine in 2021. It assigned 265 patients with colorectal peritoneal metastases — all with PCI below 25, all receiving modern perioperative systemic chemotherapy — to either CRS alone or CRS plus HIPEC using oxaliplatin. The headline result was striking: there was no statistically significant difference in overall survival between the two groups. CRS plus HIPEC did not significantly improve overall survival compared to CRS alone in patients receiving modern systemic chemotherapy.

This finding created enormous controversy in the colorectal oncology community — because it contradicted the accumulated observational data from dozens of single-centre series that had established HIPEC as standard treatment. The debate has not been fully resolved, and it is important for any HIPEC candidate to understand it.

What PRODIGE 7 means for your decision

Several important criticisms of PRODIGE 7 have been published. The oxaliplatin dose used in the HIPEC arm was lower than that used in many other centres, and the HIPEC duration was shorter at 30 minutes rather than 60 to 90 minutes used elsewhere. The HIPEC arm also showed significantly higher morbidity, suggesting that the oxaliplatin dose — though lower — was still causing additional toxicity that may have offset survival benefits. Subgroup analyses suggested that patients with lower PCI scores derived more benefit from HIPEC. And the overall survival in both arms was remarkably good — 41 months and 41.7 months respectively — suggesting that highly selected patients undergoing complete CRS do well regardless of whether HIPEC is added.

The current position of most expert peritoneal surface oncology centres worldwide — including those in India — is that PRODIGE 7 has changed the conversation around HIPEC but has not ended it. CRS alone remains a valid and potentially curative treatment for selected patients with colorectal peritoneal metastases. Whether HIPEC should be added to CRS requires discussion of the individual patient's PCI, molecular profile, disease distribution, and overall fitness — rather than automatic application of either "always HIPEC" or "never HIPEC" after PRODIGE 7.

What Happens During HIPEC — Step by Step

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A detailed account of what happens during HIPEC helps patients and families understand what they are consenting to and what the recovery involves.

1. 1

   General anaesthesia and opening the abdomen

   The patient is under general anaesthesia with an epidural for post-operative pain management. The abdomen is opened with a midline incision from sternum to pubis. A thorough abdominal exploration is performed — every surface is inspected and the PCI is formally scored intraoperatively to confirm that complete cytoreduction is achievable before proceeding.

2. 2

   Cytoreductive surgery — removal of all visible deposits

   Each peritoneal region is systematically addressed. Omentectomy — removal of the omentum — is performed as a standard component. Parietal peritonectomy strips tumour-bearing peritoneum from the abdominal wall. Bowel resections are performed where mesenteric or serosal deposits cannot be cleared without sacrifice of that segment. Splenectomy may be required if the splenic hilum is involved. This component alone takes 4 to 8 hours depending on disease extent.

3. 3

   HIPEC perfusion — heated chemotherapy wash

   Perfusion catheters are placed in the abdomen and connected to the HIPEC machine. The chemotherapy solution — oxaliplatin in saline for colorectal peritoneal disease — is heated to 41 to 43 degrees Celsius and circulated continuously for 30 to 90 minutes. The surgeon manually distributes the solution throughout the peritoneal cavity. Temperature is monitored continuously at multiple intraabdominal sites to maintain the therapeutic range throughout the perfusion.

4. 4

   Bowel reconstruction and abdominal closure

   After the HIPEC wash is drained and the abdomen rinsed, bowel anastomoses are created where resections were performed. The decision about whether to create a protective diverting stoma is made at this point based on the number and complexity of anastomoses. The abdomen is closed in layers. A temporary ileostomy may be brought out through a separate small incision to divert the faecal stream away from high-risk anastomoses during healing.

5. 5

   ICU admission and post-operative monitoring

   All HIPEC patients are admitted directly to the ICU after surgery. Monitoring covers fluid balance, renal function (oxaliplatin is nephrotoxic at high doses), blood counts, electrolytes, and anastomotic integrity. Most patients spend 2 to 3 days in ICU before transfer to a high-dependency or standard surgical ward. The epidural provides excellent pain control and allows early mobilisation.

Recovery — What to Expect and When You Can Fly Home

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Recovery from HIPEC is substantially longer than from standard laparoscopic colectomy. Patients and families need to plan for a 6 to 8 week India stay as a realistic minimum, and some patients require longer. Understanding the recovery timeline in advance removes the anxiety of uncertainty and allows practical planning.

Days 1 to 3 — ICU

Most patients are in the ICU for 2 to 3 days post-operatively. The focus is monitoring fluid balance, renal function, and haemodynamic stability. Pain is well-controlled with the epidural. Patients are typically drowsy and may have a degree of temporary confusion — expected after 8 to 14 hours of general anaesthesia. The family member or companion GAF Healthcare has helped you bring with you will be your most important support during this period.

Days 3 to 10 — Surgical ward

After ICU, patients move to a surgical ward room. The epidural is removed around day 3 to 4 and pain management transitions to oral medications. Physiotherapy begins — sitting out of bed, walking short distances, graduated activity. Bowel function returns gradually, which is slow after the extensive bowel handling of cytoreductive surgery. Patients begin liquid diet when bowel sounds return and progress to soft food over several days. Most patients are discharged from hospital between day 10 and day 14 for uncomplicated HIPEC, or longer if there have been complications.

Weeks 2 to 6 — Accommodation near hospital

After discharge from hospital, patients stay in accommodation near the hospital for an extended recovery period before flying home. GAF Healthcare arranges service apartments with kitchens — important because post-HIPEC dietary requirements differ from normal eating, and having control over food preparation supports better recovery. Regular outpatient visits to the surgical team monitor wound healing, stoma function if present, blood counts, and renal function recovery. Most surgeons require patients to demonstrate adequate oral intake, pain control on oral medications only, and stable blood tests before approving the flight home.

Most international patients are cleared to fly home between 6 and 8 weeks after HIPEC. Long-haul flights require deep vein thrombosis prophylaxis — anticoagulation injections — and full-length compression stockings. Patients with stomas will need adequate stoma supplies for the journey and arrangements in place for stoma care at home. For patients whose stoma reversal is planned, this typically happens 8 to 12 weeks after HIPEC, which means a return trip to India or arrangement for the reversal in the home country.

Months 2 to 4 — Adjuvant chemotherapy

Most patients who undergo HIPEC for colorectal peritoneal metastases receive systemic adjuvant chemotherapy after surgery, typically starting 6 to 8 weeks post-operatively once recovery is adequate. This chemotherapy continues the systemic disease control that the perioperative chemotherapy began, addressing any microscopic systemic deposits that the HIPEC procedure did not reach. The chemotherapy protocol is the same discharge package approach used for colon cancer surgery — started in India if timing allows, or begun at home with the India protocol if the patient has returned by the time chemotherapy is due.

What HIPEC Costs in India vs the World

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The following costs are based on 2026 tariff data from GAF Healthcare's partner hospitals. The HIPEC surgical package covers specific items — understanding what is and is not included prevents surprise billing.

What the HIPEC surgical package includes	Included ✓	Separate cost ✗
Surgeon, anaesthetist, and assistant fees	✓
Operating theatre — full session charge	✓
HIPEC machine usage and perfusion circuit	✓
Intraperitoneal chemotherapy drugs (oxaliplatin)	✓
ICU stay — 2 to 3 days	✓
Private ward — quoted number of nights	✓
Standard post-operative medications and blood tests	✓
Pre-operative CT and staging workup		✗ $900–$1,500
Molecular profiling (KRAS, MSI, BRAF, HER2)		✗ $280–$460
Adjuvant chemotherapy after HIPEC		✗ Separate cost
ICU stay beyond 3 days if complications arise		✗ Billed separately

GAF Healthcare asks each hospital specifically what will be billed outside the HIPEC package before sharing any cost estimate with patients.

Country	HIPEC all-in cost	Hospital stay	Notes
India	$9,000 – $16,000	10–14 days	JCI/NABH specialist centres. Includes CRS, HIPEC machine, ICU, ward.
UAE	$35,000 – $60,000	12–16 days	Limited HIPEC volume at UAE centres.
Thailand	$20,000 – $35,000	12–16 days	Available at Bumrungrad and select centres.
UK (private)	£55,000 – £90,000	12–16 days	NHS HIPEC waiting times can exceed 4 months.
USA	$80,000 – $150,000	12–18 days	Out-of-pocket for international patients.

Sources: GAF Healthcare Hospital Cost Database 2026 · Tata Memorial Centre HIPEC programme tariff data · CMS Hospital Price Transparency Data USA 2026 · NHS Private Patient Tariff 2025 · Bumrungrad International Hospital Bangkok tariff data

"I was told in Nairobi that my peritoneal cancer was inoperable. Tata Memorial reviewed my CT and said my PCI was 14 — they had done over 300 HIPEC procedures. The surgery was 11 hours. I spent three weeks recovering in Mumbai. Two years on, my scans are clear. The total cost was USD 14,200."

Which Hospitals in India Perform HIPEC at Sufficient Volume

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HIPEC is one of the procedures where volume matters most. The learning curve is steep, the complication rate is meaningful even at experienced centres, and the difference in outcomes between high-volume and low-volume surgeons is substantial. The minimum threshold GAF Healthcare uses when considering HIPEC referrals is a surgeon who has personally performed 50 or more HIPEC procedures, not including cases supervised during training.

Tata Memorial Hospital, Mumbai — India's highest HIPEC volume

Tata Memorial Hospital is India's premier HIPEC centre. The peritoneal surface oncology programme at TMH has treated more patients with HIPEC for colorectal and other peritoneal malignancies than any other Indian institution. The surgical team has published its outcomes data in peer-reviewed journals. The combination of TMH's colorectal oncology volume — 800 to 1,000 new colorectal cancer cases per year — and its dedicated peritoneal surface oncology programme creates the case mix and multidisciplinary depth required for optimal HIPEC outcomes. This is the strongest clinical recommendation for HIPEC candidacy assessment in India, particularly for complex cases or those with higher PCI scores approaching the threshold.

The practical consideration for international patients is that Tata Memorial is a government autonomous institution — efficient and clinically outstanding but with a different patient environment to private hospitals. GAF Healthcare advises international patients on the practical aspects of navigating Tata Memorial as a foreign patient before making a referral.

Medanta The Medicity, Gurgaon — Strongest private sector HIPEC programme

Medanta's Institute of Digestive and Hepatobiliary Sciences performs HIPEC as part of a comprehensive peritoneal surface oncology programme. The surgical team has performed over 150 HIPEC procedures with published outcomes. Medanta's specific advantage for HIPEC candidates with colon cancer is the integration of the HIPEC programme with one of India's strongest hepatobiliary surgical teams — for the subset of Stage 4 patients who have both peritoneal and liver involvement, the ability to address both in a coordinated programme at a single institution is valuable. Medanta's international patient floor provides the most comfortable inpatient environment in the Delhi-NCR region. For international patients from the Gulf and Africa, Medanta's location 20 minutes from IGI Airport is a practical advantage.

Apollo Hospitals Chennai and Fortis Memorial Gurgaon — Secondary HIPEC centres

Both Apollo Chennai and Fortis Memorial Gurgaon perform HIPEC within their colorectal oncology programmes. Neither has the dedicated peritoneal surface oncology programme volume of Tata Memorial or Medanta, but both have experienced surgeons who have completed a meaningful number of HIPEC procedures. For patients with lower PCI scores — below 12 to 15 — where the complexity of the cytoreductive surgery is lower and complete resection is more readily achievable, Apollo and Fortis represent credible alternatives at JCI-accredited private hospital facilities.

Survival Data — Honest Numbers from Published Trials

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The survival data for HIPEC in colorectal peritoneal metastases comes from three sources: pre-PRODIGE 7 observational series from high-volume centres, the PRODIGE 7 randomised trial itself, and post-PRODIGE 7 registry and cohort data. All three sources are relevant to any patient making a decision about HIPEC.

Scenario	Outcome	Source	Key factor
CRS + HIPEC — complete CRS (CC-0)	Median OS 30–63 months	Elias et al. Annals Surgery 2010 · Multiple registry series	Complete CC-0 cytoreduction achieved
CRS + HIPEC — PCI below 10	5-year survival 20–30%	Glehen et al. Annals Surgery 2004 · RENAPE registry	Low burden disease + complete resection
PRODIGE 7 — CRS + HIPEC arm	Median OS 41.7 months	NEJM 2021 · n=133 patients	Highly selected patients + modern chemo
PRODIGE 7 — CRS alone arm	Median OS 41.2 months	NEJM 2021 · n=132 patients	No significant difference from HIPEC arm
CRS only — without HIPEC — historical	Median OS 12–24 months	Pre-modern-chemo era series	Older data — modern chemo has improved outcomes
Systemic chemo only — no surgery	Median OS 12–18 months	Franko et al. Ann Oncol 2012 · Historical series	Surgery consistently improves outcomes
Tata Memorial HIPEC programme — published data	Comparable to international series	Indian Journal of Surgical Oncology · Multiple publications	Volume and selection criteria equivalent to Western specialist centres

Sources: Glehen et al. (Annals of Surgery 2004) · Elias et al. (Annals of Surgery 2010) · PRODIGE 7 trial (NEJM 2021) · RENAPE National Registry France · Tata Memorial Centre published HIPEC outcomes · GAF Healthcare clinical documentation

How to Get a HIPEC Eligibility Assessment

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The most important first step is not to book flights. It is to find out whether you are a HIPEC candidate — and that determination can be made from your existing imaging without you travelling. Many patients who are told locally that their peritoneal disease is too extensive for surgery find, when their CT is reviewed by a peritoneal surface oncology specialist, that their estimated PCI is within the operative range. Equally, some patients who are told they are HIPEC candidates find that a second expert assessment suggests their disease distribution is not favourable for complete cytoreduction. Either way, the formal candidacy assessment comes first.

1. 1

   Send your most recent CT or MRI scan plus molecular profiling

   The most recent staging CT of the chest, abdomen, and pelvis — ideally within 4 to 8 weeks — as DICOM files or high-resolution images. Include your colonoscopy and pathology report, CEA, and molecular profiling results. If you have had diagnostic laparoscopy with a formal PCI score, include that report.

2. 2

   Receive HIPEC candidacy assessment within 72 hours

   GAF Healthcare forwards your imaging to a peritoneal surface oncology surgeon at Tata Memorial and Medanta. You receive a written HIPEC candidacy assessment — including the surgeon's estimated PCI from your imaging, their recommendation on whether HIPEC is indicated, what the surgical plan would involve, and an itemised cost estimate. This assessment does not commit you to any treatment.

3. 3

   Medical visa and travel planning

   India's e-Medical Visa covers the patient and one family member — a companion for HIPEC surgery is essential, not optional. GAF Healthcare provides the hospital visa support letter. HIPEC patients should plan for a minimum 6 to 8 week India stay and arrange accommodation accordingly.

4. 4

   Arrival and pre-operative assessment

   Airport transfer arranged. Within 24 to 48 hours, the hospital conducts a comprehensive pre-operative assessment — repeat staging CT or MRI, cardiac and pulmonary assessment, nutritional status review, and anaesthetic assessment. The peritoneal surface oncology team formally reviews your candidacy with up-to-date imaging before proceeding to surgery.

5. 5

   HIPEC surgery within 7 to 10 days of arrival

   The HIPEC procedure is scheduled after pre-operative assessment is complete. Surgery takes 8 to 14 hours. ICU for 2 to 3 days. Hospital ward for 7 to 11 days. Discharge to accommodation near hospital for 4 to 6 weeks of recovery before flying home.

6. 6

   Fly home with complete post-HIPEC protocol

   Discharge package includes the operative report, histopathology, completeness of cytoreduction grade, molecular profiling, adjuvant chemotherapy protocol, stoma care instructions if applicable, and covering letter for the home oncologist and stoma nurse. India surgical team available for video consultation throughout recovery.