Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is one of the most complex abdominal surgical procedures performed for conditions causing peritoneal carcinomatosis. This includes diseases such as pseudomyxoma peritonei, ovarian cancers, and colorectal cancers with peritoneal metastasis.
While these procedures were once associated with high mortality and morbidity, advancements in surgical techniques, anaesthesia, and perioperative care now make CRS with HIPEC much safer. At Porunai Hospitals, this advanced cancer treatment is performed with excellent outcomes, thanks to the coordinated efforts of a multidisciplinary team.
This case study shares the journey of a 56-year-old woman diagnosed with ovarian cancer, highlighting the challenges, surgical expertise, and teamwork that led to her successful recovery.
Initial Diagnosis and Assessment
The patient, a 56-year-old woman with diabetes mellitus, presented with abdominal discomfort and distension. Following clinical assessment, imaging (CT scan of the abdomen and pelvis), and tumour markers (CA 19-9 and CA 125, both within normal limits), she was diagnosed with carcinoma of the ovary.
Diagnostic laparoscopy with Peritoneal Carcinomatosis Index (PCI) scoring revealed:
- Multiple peritoneal deposits, including deposits over the liver capsule
- Bilaterally enlarged ovaries
- PCI score of 13
Biopsy confirmed serous adenocarcinoma of the ovary. After discussion in the hospital’s tumour board, the patient underwent neoadjuvant chemotherapy (NACT) with three cycles, which showed excellent clinical, biochemical, and imaging responses. Based on this, she was planned for interval CRS with HIPEC.
Thorough Pre-Operative Planning and Rehabilitation
Porunai Hospitals emphasises holistic preparation before such complex surgeries:
- Counselling and Consent: The patient and her family were extensively counselled about the disease, treatment options, procedure complexity, risks, and expected outcomes. Ample time was given to make an informed decision, supported by reassurance of safe and comprehensive care.
- Rehabilitation: Pre-operative physiotherapy, pulmonary rehabilitation, and protein supplementation were provided to enhance post-operative recovery.
- Blood Products: Adequate preparation of packed red cells, platelets, fresh frozen plasma (FFP), and albumin infusions ensured readiness for intraoperative requirements.
Advanced CRS With HIPEC Performed at Porunai Hospitals
The procedure was carried out following a structured and methodical approach.
Anaesthesia and Monitoring
The patient was prepared with central venous access, arterial lines, and epidural catheter insertion. Intubation was followed by positioning in lithotomy with shoulder supports. In addition to the WHO safety checklist, a customised procedural checklist was used to ensure no step was missed.
CRS
After a midline laparotomy, a thorough examination of the entire abdominal viscera was performed. Multiple peritoneal deposits were noted over the pouch of Douglas (POD), bladder peritoneum, omentum, and right subdiaphragmatic area. The deposits showed a good response to prior chemotherapy.
The surgical team then performed a total peritonectomy, which was completed in five parts, with the procedures mentioned below to remove all visible disease.
- Anterior parietal peritonectomy
- Right subdiaphragmatic peritonectomy
- Left subdiaphragmatic peritonectomy
- Total omentectomy with omental bursectomy
- Pelvic peritonectomy with bladder peritonectomy
- Hysterectomy with B/L Salpingo-oophorectomy and Cholecystectomy
HIPEC
After CRS, HIPEC was performed using mitomycin at 42°C for 1 hour through the open technique. This step targeted microscopic disease left behind after surgical removal.
The anaesthesia team managed significant physiological challenges during hyperthermia, including:
- High fluid requirements (3–7 ml/kg body weight)
- Albumin infusions
- Core temperature regulation
- Renal output maintenance
- Frequent ABG monitoring (every 15 minutes)
Strict safety protocols were followed to prevent chemotherapy contamination through staff protection, smoke evacuators, and careful handling. After completion, the abdomen was thoroughly irrigated with saline, drains were placed, and closure was done.
Duration and Blood Loss: The total procedure lasted ~10 hours, with a blood loss of ~400 ml, which was appropriately replaced.
Comprehensive Post-Operative Care and Recovery
The patient’s post-operative course was carefully monitored to ensure a safe and smooth recovery.
Immediate ICU Care
- The patient was electively ventilated overnight and extubated the next day.
- High-flow nasal oxygen (HFNO) support was provided for 48 hours.
- Pain was managed through epidural catheters.
- Albumin infusions and total parenteral nutrition were initiated.
- Daily monitoring: CBC, electrolytes, LFT, coagulation profile, chest X-ray, ABG.
Day 3–5
- Patient transitioned from HFNO to room air.
- Mobilisation and pulmonary rehabilitation started.
- An oral diet was gradually introduced as bowel function returned.
Day 5–8
- Drains, catheters, and central lines removed.
- Patient mobilised well, tolerating oral diet.
- Close monitoring of immune suppression due to chemotherapy.
Discharge
The patient was discharged on post-operative day 8 in stable condition.
Expert Multidisciplinary Team Involved and State-of-the-Art Facilities
The procedure was performed by Dr. Harish Kumar, Surgical Oncologist, and his team.
Successful Outcome and Restored Health
This case demonstrates that although CRS with HIPEC is a complex and lengthy procedure, with careful preparation, surgical precision, anaesthesia management, and standardised perioperative care, patients can achieve safe and positive outcomes.
At Porunai Hospitals, the availability of such advanced cancer treatments in a tier-3 city provides patients with access to world-class care at affordable costs — treatment options that were once available only in metro cities.