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CION Cancer Clinics
Cytoreductive surgery plus HIPEC: the two halves of the operation | CION Cancer Clinics
Cytoreductive surgery with HIPEC is one long operation in two halves. First the surgeon removes every cancer deposit that can be seen on the lining of the abdomen. Then warm chemotherapy is washed around the inside to reach cells too small to see. The surgical half takes most of the day and decides whether the wash happens at all. This page explains both halves and what each one asks of you. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- What does cytoreductive surgery with HIPEC actually involve?
- What happens first, and what happens last?
- What can "removing the cancer" actually mean?
- How do the two halves compare?
- What families assume about the two halves, and what is true
- Who does this operation not suit, and what this page cannot tell you?
- Common questions about cytoreductive surgery and HIPEC
The short answer
What does cytoreductive surgery with HIPEC actually involve?
It is one long operation in two halves. In the first half, the surgeon removes every cancer deposit that can be seen on the lining of the abdomen. In the second half, warm chemotherapy is washed around the inside of the abdomen to reach the cells too small to see. The first half takes most of the day and decides whether the second half is worth doing.
The first half: cytoreductive surgery
Cytoreduction means reducing the amount of cancer. In practice the surgeon aims to leave nothing visible behind. That can mean peeling cancer off the lining, removing the lining itself in places, and taking out organs the cancer has grown into. How much is removed is decided inside the abdomen, not beforehand, because scans undercount the small deposits.
The second half: the heated wash
Once the visible disease is out, tubes are placed, and warm chemotherapy fluid is circulated for an hour or so. It soaks into the exposed surfaces to a very shallow depth. It cannot treat a deposit the surgeon left behind, which is why the two halves are not equal partners.
You will sometimes see the whole operation written as CRS plus HIPEC, or CRS-HIPEC. It is the same thing.In order
What happens first, and what happens last?
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The abdomen is opened and scored
Through a long cut down the middle, the surgeon looks at every region and gives a score for how much cancer is present. This is the point at which the plan is confirmed or changed.
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The decision to go ahead
If the disease is far more than expected, or sits somewhere it cannot be safely removed, the surgeon may close without doing the wash. This is not a failure of the team. It is the honest answer to a question the scans could not settle.
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The clearance
Deposits are removed region by region. Lining is stripped where it is involved, and organs are removed where they must be. This is the long part, and the part most of the recovery comes from.
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The completeness check
The surgeon records how much disease, if any, is left. Only when the clearance is complete or very nearly complete does the wash go ahead.
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The heated wash
Warm chemotherapy circulates through the abdomen for about an hour while the anaesthetist keeps your body temperature steady.
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Joins, drains and closing
Any bowel that was cut is joined back, or a stoma is made if a join is not safe. Drains are placed and the wound is closed. You wake in intensive care.
Not sure whether this applies to you?
Ask an oncologistThe surgical half
What can "removing the cancer" actually mean?
It depends entirely on where the deposits sit. These are the parts most often involved.
The lining itself
Called peritonectomy. The surgeon peels the involved lining off the wall of the abdomen, the underside of the diaphragm, or the pelvis. The body grows a new lining over the months that follow.
The fatty apron
The omentum hangs over the bowel like an apron and is one of the first places these cancers settle. It is removed in almost every case. Living without it causes no lasting problem.
Organs the cancer has grown into
Which ones depends on the pattern of spread. None is removed unless the cancer is on it.
Most often
- Spleen and gallbladder
- Part of the small or large bowel
- Womb and ovaries, in women
A stoma, sometimes
If bowel is removed and the join is not safe to make on the day, the bowel end is brought out onto the skin. Often this is temporary and is reversed later. Ask before the operation whether it is likely.
Side by side
How do the two halves compare?
Cytoreductive surgery
HIPEC wash
Removes disease the surgeon can see
Targets cells too small to see
Takes several hours, often most of the day
Takes about an hour
Causes most of the recovery and most of the risk
Adds some risk to the kidneys and the bowel joins
Decides whether the wash goes ahead
Only done if the clearance was complete or nearly so
Every centre doing this must be skilled at it
Needs a perfusion machine and a trained team
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Commonly believed
What families assume about the two halves, and what is true
"The chemotherapy is the clever part. The surgery is just clearing up."
The reverse is closer to the truth. Centres measure their results by how complete the surgical clearance was. A wash after an incomplete clearance adds risk with little to show for it.
"If they take out fewer organs, the operation went better."
The number of organs removed reflects where the cancer was, not how well the surgery went. A longer list can mean a complete clearance of widespread disease. A short list can mean the surgeon stopped early.
"They can do the wash on its own, without the big operation."
A heated wash without clearance is rarely offered, because the drug only soaks in a paper-thin layer. A different treatment, PIPAC, sprays chemotherapy through keyhole ports without major surgery, but it is a different tool for a different situation.
"Once it is done, no more chemotherapy is needed."
Most plans still include chemotherapy through a drip before the operation, after it, or both. The wash treats the lining only. Your medical oncologist plans the rest.
Being straight with you
Who does this operation not suit, and what this page cannot tell you?
The operation is not offered when the deposits are too widespread to remove, when the cancer has also spread to the liver, lungs or bones, or when the person is not fit enough for a long operation and a slow recovery. It is also offered more cautiously for some cancer types than others, because the evidence differs.
Why the surgeon cannot promise the second half
The wash is only given if the first half went well enough. Everyone goes into theatre knowing the wash might not happen. If you wake and are told it was not done, ask why. The usual reasons are more disease than the scans showed, or disease in a place that could not be cleared safely.
What this page cannot tell you
It cannot tell you whether this operation is right for you or the person you are reading for. That is a tumour board decision, made on your scans, your fitness tests and your cancer type. It cannot tell you how long anyone will live after it, and it cannot tell you which organs will be removed in your case. Only the surgeon, on the day, knows that.
Ask your surgeon two things: what the plan is if the disease is more than expected, and whether a stoma is likely.
Did you know
The surgeon scores the abdomen twice: once when it is opened, for how much cancer is there, and once at the end, for how much was left. Both scores go in your operation notes, and you are entitled to ask what they were.
Questions we are asked
Common questions about cytoreductive surgery and HIPEC
How long does the whole operation take?
Usually most of a day, sometimes longer. The surgical half varies enormously with how much disease there is and where it sits. The wash itself is about an hour. Ask the team to give the family a rough time to expect, and to send word out if it runs long.
Can the surgery be done without the wash?
Yes, and sometimes it is, either by plan or because the clearance was not complete enough for the wash to help. For some cancers, surgery alone is now thought to carry most of the benefit. Your surgeon should explain which applies to you before the day.
Will I have a stoma?
Not always. It depends on whether bowel is removed and whether the join is safe to make on the day. Where a stoma is made, it is often temporary. Ask beforehand how likely it is in your case, so that it is not a shock when you wake.
Why can they not tell me beforehand what will be removed?
Because CT scans undercount small deposits on the lining. The surgeon can give a likely list from the scans, but the final list is decided by what is actually found once the abdomen is open. A good surgeon will tell you the range of possibilities rather than a single answer.
Is the heated wash the risky part?
Most of the risk comes from the surgery, not the wash. Removing lining and organs is what leads to bleeding, leaks at bowel joins and a slow recovery. The wash adds some strain on the kidneys and can slow healing of joins, which is why your fitness is checked so carefully first.
What is the difference between CRS and peritonectomy?
Peritonectomy is one part of CRS. It means stripping the lining from a region of the abdomen. CRS is the whole surgical half, which can include several peritonectomies plus removing organs. If your report lists peritonectomy procedures, that is what was stripped.
Will I need chemotherapy through a drip as well?
Often, yes. Many plans give chemotherapy before the operation to shrink the disease, and after it to deal with any cells elsewhere in the body. The wash treats the lining of the abdomen only. Your medical oncologist and surgeon plan this together for your cancer type.
How do I find out how complete the surgery was?
Ask for the completeness score, written as CC-0 to CC-3. CC-0 means nothing visible was left. It is in the operation notes and your surgeon can tell you at the first review. Knowing it helps you understand why the wash was or was not done.
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Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
Surgical Oncologist
Surgical Oncologist
Dr. Vinay Mamidala
MBBS, MS(General Surgery), M.Ch(Surgical Oncology), FMAS, FARIS(Ongoing)
Surgical Oncologist
Radiation Oncologist
Radiation Oncologist
Radiation Oncologist
Hematologist
Surgical Oncologist
Dr. Vajja Sandeep Kumar
MBBS, MS (General Surgery), DrNB (Surgical Oncology), FALS Oncology
Surgical Oncologist
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Sources
- NICE — Cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis (IPG688)
- Cancer Research UK — Pseudomyxoma peritonei
- Macmillan Cancer Support — Surgery
- American Cancer Society — Chemotherapy
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
HIPEC: what heated chemotherapy in the abdomen actually isStart here if the word is new to youPeritonectomy: stripping the lining of the abdomenThe surgical half in more detailOrgans that may be removed during cytoreductionWhat the surgeon may need to take out, and whyCompleteness of cytoreduction scoreThe score that decides whether the wash goes aheadDrains, tubes, lines and cathetersWhat you will wake up with
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