Mesothelioma Cytoreductive Surgery With HIPEC
Mesothelioma cytoreductive surgery with HIPEC is a combination of treatments for peritoneal mesothelioma. The procedure, often called the HIPEC surgery, is used to remove and kill tumors in the abdominal cavity. The first part is surgical resection. The second part is liquid chemotherapy.
Written by Karen Ritter, RN BSN
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Important Facts About Cytoreductive Surgery With HIPEC for Mesothelioma
- Cytoreductive surgery with HIPEC is a cancer treatment for peritoneal mesothelioma. It’s often called the “HIPEC surgery” or “HIPEC procedure.”
- Cytoreductive surgery is a debulking procedure. During debulking, doctors look for and remove all visible tumors one by one. Cytoreductive surgery for peritoneal mesothelioma usually involves a peritonectomy. This is the surgical removal of the peritoneum, which lines the abdominal cavity.
- HIPEC is an acronym for “hyperthermic intraperitoneal chemotherapy.” Hyperthermic means “hot”, and the therapy involves delivering hot liquid chemotherapy drugs into the abdominal cavity.
- Cytoreductive surgery with HIPEC is a time‑consuming surgery due to the debulking process. HIPEC surgery can take up to 14 hours.
- Survival rates for this surgery vary. Some cancer centers report average survival of 3‑5 years following the procedure.
How to Get Cytoreductive Surgery With HIPEC for Your Mesothelioma
If you’re wondering how to get mesothelioma cytoreductive surgery with HIPEC, you should contact our patient advocates for assistance. They’ll help you through these three steps to get highly rated medical care from a specialist:
Following your official diagnosis of peritoneal mesothelioma, contact a cancer center for a second opinion. We can help you find a cancer center close to where you live.
Look up all information about cytoreduction with HIPEC for peritoneal mesothelioma. This includes survival rates, side effects, recovery time and patient recommendations.
Contact a peritoneal mesothelioma surgeon to schedule a consultation. This is the most important step, as you don’t want an inexperienced doctor performing your surgery. Let us help you find the best surgeon possible through our free Doctor Match program.
Overview of Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
Cytoreduction with HIPEC is a multi‑part surgical procedure for malignant peritoneal mesothelioma. The goal is to remove all or most of the tumors and kill as many cancer cells as possible in the abdominal cavity.
Doctors use cytoreductive surgery to remove all visible tumors. HIPEC is then used to kill any remaining tumors or cancer cells hidden from plain sight.
Where Was Cytoreductive Surgery With HIPEC for Mesothelioma Developed?
Cytoreductive surgery with HIPEC was developed at the end of the 20th century, thanks in large part to mesothelioma specialist Dr. Paul Sugarbaker of the Washington Cancer Institute. Dr. Sugarbaker’s influence on the development of cytoreduction with HIPEC is why it’s often called the “Sugarbaker Technique.”
The development of cytoreduction with HIPEC for peritoneal mesothelioma materialized in the 1990s. During this decade, Dr. Sugarbaker and colleagues introduced the Peritoneal Cancer Index (PCI) to determine the stage of the disease and whether doctors can perform cytoreductive surgery safely.
In 1995, Dr. Sugarbaker then introduced the peritonectomy to cytoreduction with HIPEC for peritoneal mesothelioma. He also improved upon earlier approaches to heated intraoperative chemotherapy by using an open abdominal technique, which provided direct access to remaining tumors.
Cytoreductive surgery is a procedure to manually remove tumors from the body. It’s the only mesothelioma surgery to try and remove mass amounts of peritoneal mesothelioma tumors.
Doctors focus on visible tumors and extract them one by one. This process is called “debulking.” The goal of cytoreduction is to leave only microscopic cancer cells behind.
Aside from the debulking procedure, cytoreductive surgery for peritoneal mesothelioma involves a peritonectomy. Another part of the process is HIPEC.
Depending on the severity of the disease, doctors may have to remove part or all of an organ in the abdominal cavity. The organs are only removed if the tumors cannot be separated from the organ’s surface.
According to the Tufts Medical Center website, where peritoneal mesothelioma surgeon Dr. Martin Goodman works in Boston, Massachusetts, the organs able to be safely removed during cytoreductive surgery are the:
- Part of the small or large intestine
An article in the Annals of Surgical Oncology said surgeons may remove the pancreas, kidney, ureter, bladder and uterus without increasing severe complications or mortality rate.
HIPEC, or hyperthermic intraperitoneal chemotherapy, is an intraoperative therapy used for peritoneal mesothelioma. Another name for it is “hot chemotherapy.” It’s an innovative treatment for mesothelioma.
HIPEC sends chemotherapy drugs directly into the disease’s location. This avoids some side effects associated with systemic (intravenous) chemotherapy.
Doctors create a liquid chemotherapy cocktail, usually with cisplatin included. Other drugs used in HIPEC are doxorubicin and mitomycin. They’ll then heat the chemotherapy drugs to a specific temperature and deliver the therapy directly into the abdominal cavity.
Doctors rock the patient back and forth to “bathe” the entire abdominal cavity in the chemotherapy drugs. This is a tedious process but ensures the therapy reaches every corner of the cavity and small crease between organs.
What Is the Peritoneum?
The peritoneum is a mesothelial tissue lining around your abdominal cavity. It is made up of fluid and mesothelial cells. The lining acts as a protective layer for the abdominal cavity and its many organs.
The peritoneum has two cell linings: the parietal peritoneum and visceral peritoneum. The parietal peritoneum is the outer layer, next to the abdominal and pelvic walls. The visceral peritoneum is the inner layer of tissue covering the abdominal organs.
The peritoneal cavity is the space between the parietal and visceral tissue linings. This space includes fluid, which allows the linings to slide against one another with little resistance. This fluid also enables the peritoneum to allow for abdominal organ movement.
When tumors form in either of these linings, they multiply and grow. This takes up space in the cavity, disrupting the peritoneum’s normal functioning. This causes peritoneal mesothelioma side effects, such as abdominal pain and loss of appetite.
A peritonectomy is surgically removing part or all of the peritoneum. It’s part of the cytoreductive surgery process.
Since the peritoneum is where peritoneal mesothelioma forms, doctors remove this lining to extract many of the tumors making up the cancer. Removing the peritoneum can also reduce some side effects.
Multimodal Therapies With Cytoreductive Surgery and HIPEC
Systemic (intravenous) chemotherapy is the primary treatment option paired with cytoreductive surgery and HIPEC. Doctors can use mesothelioma chemotherapy either before or after cytoreductive surgery:
- Using chemotherapy before surgery is neoadjuvant therapy
- Using chemotherapy after surgery is adjuvant therapy
Doctors may use other types of chemotherapy after surgery. Dwell chemotherapy involves leaving the ports used during HIPEC surgery in the abdomen. Doctors then deliver chemotherapy into the abdominal cavity multiple times in the weeks following surgery.
This is the extent of multimodal therapy with cytoreductive surgery. Radiation is not an option for peritoneal mesothelioma, and immunotherapy is still in testing.
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What Happens During a Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma?
Mesothelioma cytoreduction with HIPEC is a lengthy surgery due to the debulking process. Prior to incision, the patient will be sedated with anesthesia and properly positioned for surgery. Doctors insert tubes to assist with breathing and fluid intake.
The procedure isn’t painful due to the anesthesia. However, dwell chemotherapy can be uncomfortable for patients because this is performed when the patient is awake.
HIPEC surgery can take up to 14 hours, but it usually lasts much less. Cytoreduction (debulking) is the longest step. The extent of the cancer determines how long the surgery takes.
8 Steps of Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
Here are the steps of cytoreductive surgery with HIPEC:
Incision — The surgeon creates an incision from just below the xiphoid (small bone just below the sternum) down the middle of the abdomen. This incision is called a laparotomy.
Cytoreduction — The surgeon removes as many visible tumors as possible in the abdominal cavity. Doctors also consider cytoreduction to include a peritonectomy and possible removal of organs. We split these into separate steps for clarity.
Peritonectomy — Part or all of the peritoneum is removed. The peritoneum is where peritoneal mesothelioma forms. It’s a thin lining around the abdominal cavity. The peritoneum includes two linings: parietal peritoneum (outer lining next to the abdominal wall) and visceral peritoneum (inner lining covering the abdominal organs).
Removal of other organs — If necessary, the surgeon removes any diseased organs if safe to do so. They may also remove part or all of the diaphragm (respiratory muscle) if affected by peritoneal mesothelioma tumors.
HIPEC preparation — The surgical team inserts two catheters/ports into the patient’s abdomen. These catheters deliver and drain the chemotherapy.
Reconstruction — Closing the incision during HIPEC is called the closed‑abdominal technique. Reconstruction could also happen after HIPEC, which is called the open‑abdominal technique.
HIPEC — The surgical team heats chemotherapy drugs to around 107 degrees and delivers it into the abdomen through one of the catheters. The chemotherapy is circulated through the abdominal cavity for 60‑90 minutes. The team rocks the patient to wash the area in the therapy.
HIPEC drainage — The chemotherapy is then drained from the body and doctors remove the catheters/ports.
If the patient receives dwell chemotherapy as an adjuvant treatment, doctors may leave the ports in the abdomen at the end of the surgery. This provides direct access to the disease location and a path to administer chemotherapy while avoiding the bloodstream.
Closed‑Abdominal HIPEC Versus Open‑Abdominal HIPEC
There are two main techniques for HIPEC. Some doctors use the closed‑abdominal technique while others prefer the open technique:
- Closed‑abdominal HIPEC prevents heat from escaping the abdominal cavity and diminishing the effectiveness of the drugs. It also prevents drug spillage or leakage from the abdominal cavity since the incision is closed. This aids in drug penetration into the tumors. However, this technique makes distributing the drugs evenly in the cavity more difficult.
- Open‑abdominal HIPEC leads to ideal chemotherapy drug distribution. This washes the abdominal cavity with the liquid and reaches hidden crevices. However, drug leakage and heat loss are bigger concerns.
Recovery Time After Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
According to the Johns Hopkins Medicine website, cytoreduction with HIPEC requires 2‑3 months of surgical recovery. Patients should expect to spend 10‑14 days in the hospital following surgery. HIPEC surgery recovery will continue for 6‑10 weeks after discharge from the hospital.
Following surgery, most patients go to the intensive care unit (ICU). They will be monitored carefully and receive IV fluids and pain medication to help with recovery. Patients may experience bowel issues due to the length of the surgery and extent of resection needed.
The postoperative team will monitor bowel movements, food intake and fluid intake, as well as progress with exercise (such as walking). This is all important to determine when a patient can transition from inpatient recovery to outpatient recovery.
Outpatient recovery can happen either at the patient’s home, the home of a loved one, or a medical rehabilitation facility. The outpatient recovery time varies.
Patients may remain on IV fluid treatments to ensure they receive nutrition. This also helps the digestive system recover.
This surgery requires regular follow‑up appointments with the primary specialist. These check‑ins are to monitor imaging scans for signs of mesothelioma recurrence. Doctors often ask for the first follow‑up within a few weeks after hospital discharge. They’ll continue every few months initially, then transition to every six months and eventually an annual check‑in.
Who Can Get Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma?
Patient eligibility for cytoreductive surgery with HIPEC depends on a few factors. The first is PCI score, as this summarizes how far the tumors have spread and infiltrated into organs. However, surgeons vary in opinions for whether to use surgery with higher PCI scores.
Other factors affecting who can have cytoreductive surgery with HIPEC are:
- Physical health
- Cell type
Cytoreduction With HIPEC Eligibility: PCI Score
A patient’s PCI score is a significant factor in qualifying for cytoreduction with HIPEC. This score determines how far the tumors have spread within the abdominal cavity. If the cancer is too advanced, surgery won’t remove enough of the disease to improve the patient’s prognosis. PCI score is similar to the stage of mesothelioma.
Peritoneal mesothelioma specialists have different opinions on what PCI score is too high to operate. Dr. Shanel Bhagwandin, from Jupiter Medical Center, is a peritoneal mesothelioma surgeon who offered his analysis of PCI scores and cytoreduction eligibility. He said scores higher than 20 often don’t qualify for surgery.
Cytoreduction With HIPEC Eligibility: Physical Health
Physical health is an important factor in whether a patient is eligible for invasive surgery. Since cytoreduction and HIPEC involves removing areas of the body and washing organs in hot chemotherapy, patients must be strong enough to withstand anesthesia, postoperative recovery and postoperative pain.
If the patient has a concerning medical history or lingering concerns, surgeons may avoid aggressive treatment. Operating on patients in poor health can cause severe complications.
Cytoreduction With HIPEC Eligibility: Age
Age is not the only determining factor in eligibility for the HIPEC surgery. However, younger peritoneal mesothelioma patients are more likely to be in good health and tolerate the procedure.
Alexis Kidd, a peritoneal mesothelioma survivor of more than 13 years, received cytoreductive surgery with HIPEC in her late thirties. The average age for peritoneal mesothelioma patients is between 50 and 60.
Older patients — those in their sixties or seventies — may still qualify for the HIPEC procedure. Before assuming anything, talk to a specialist about treatment options.
Cytoreduction With HIPEC Eligibility: Cell Type
Mesothelioma cell type is one of the most important aspects in determining surgery eligibility. Epithelioid mesothelioma cells are easiest to treat, mostly due to being easiest to identify and remove. Sarcomatoid cells are tougher to identify and remove. They also grow quicker than other cell types.
Some surgeons may only operate on patients with the epithelioid cell type. Others may consider operating on biphasic mesothelioma cases if the diagnosis is mostly epithelioid cells.
Life Expectancy and Survival Rates for Cytoreduction With HIPEC
Fortunately, there has been a steep improvement in the life expectancy and survival rates for peritoneal mesothelioma. Credit goes to the development and advancement of cytoreductive surgery with HIPEC.
Wake Forest Baptist Cancer Center reported a median survival of 40 months (3 years, 4 months). The five‑year survival rate was an astonishing 30%.
Survival After Cytoreduction and HIPEC with Multimodal Treatment
Adding systemic chemotherapy after cytoreduction and HIPEC can assist with lengthening survival. This is the primary option for multimodal treatment with the HIPEC procedure.
The same National Cancer Database research showed a median survival of 41.2 months (3 years, 5 months) when chemotherapy was used after surgery. This is called “adjuvant chemotherapy.”
Other options are dwell chemotherapy, which involves leaving ports in the abdomen and continuing to deliver liquid chemotherapy multiple times after surgery. For peritoneal mesothelioma, the dwell chemotherapy used is “NIPEC” (normothermic intraperitoneal chemotherapy).
Alexis Kidd received NIPEC following her HIPEC surgery. She’s one of the longest survivors of peritoneal mesothelioma, largely thanks to cytoreductive surgery with HIPEC and NIPEC.
“I remember they left two ports in my lower abdomen after surgery. That’s how we did the chemo after,” she said. “They put cisplatin in one port and laid me on my side. Then they switched sides to lay me on the other side.”
Possible Complications From Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
Patients may experience complications from cytoreductive surgery with HIPEC. Many of these are related to the digestive system. A few are:
- Gastrointestinal problems (bowel blockage, nausea and vomiting)
- Gastrointestinal perforations (a hole in the stomach, colon, bowel or small intestine)
- Pancreatic fistulas (leakage of pancreatic fluid into the abdominal cavity)
- Intraperitoneal abscesses (collections of pus)
- Gastric stasis (paralysis of the stomach)
- Pleural effusions (fluid surrounding the lungs)
Mesothelioma Recurrence After Cytoreduction With HIPEC
A report in the Journal of Gastrointestinal Oncology assessed that most patients will have recurrence after HIPEC surgery. It usually occurs within the abdominal cavity in up to 57% of patients after cytoreduction with HIPEC. This report included Dr. Edward Levine, a peritoneal mesothelioma surgeon at Wake Forest Baptist Cancer Center.
Recurrence occurs because peritoneal mesothelioma tumors hide within crevices of the abdominal cavity. The number of organs and small, hidden spaces allow tumors to escape the surgical team’s sight. While HIPEC can wash and kill these tumors, some persist past HIPEC and even dwell chemotherapy.
Fortunately, select patients can have a repeat of cytoreductive surgery with HIPEC. A second surgery can improve the already‑stellar survival times for this operation:
- A 2014 study of 65 patients reported a median survival of nearly four years.
- A study one year later, of 44 patients, reported a median survival of 54 months (4.5 years).
Mortality From Cytoreductive Surgery With HIPEC
The mortality for cytoreductive surgery with HIPEC is lower than many other operations labeled “risky.” Researchers from the University of Nebraska‑Omaha Cancer Center reported a 30‑day mortality rate of 1.1%. This was much lower than the mortality rates for the following surgeries:
- Tri‑segmental hepatectomy (a type of surgery that removes all or part of the liver)
- Right lobe hepatectomy (a type of surgery that removes all or part of the liver)
- Pancreaticoduodenectomy (surgery to remove cancer from the pancreas)
- Esophagectomy (surgery to remove all or part of the esophagus)
Quality of Life After Cytoreduction With HIPEC
Quality of life is a significant concern for patients considering peritoneal mesothelioma surgery. Increased discomfort is always possible following any major operation.
Researchers at Wake Forest Baptist Cancer Center reported improvement in patient quality of life following the HIPEC procedure. Their physical functioning initially worsened but then reached preoperative normalcy at the one‑year mark.
Other findings were:
- General health improved by the six‑month mark after surgery
- Emotional well‑being and social functioning improved after surgery
- Physical pain decreased after surgery
The researchers wrote that patients “may tolerate HIPEC well and have good overall quality of life postoperatively.” Alexis Kidd herself vouches for cytoreduction with HIPEC for her own quality of life.
“That’s miraculous to me.”
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Doctors Who Perform Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
Patients have a long list of options for doctors who perform cytoreductive surgery with HIPEC. There are surgeons in each region of the country who specialize in peritoneal mesothelioma. They work at the top cancer centers in the world, with vast resources at their disposal.
Some of the top doctors who perform cytoreductive surgery with HIPEC are:
- Dr. Richard Alexander, Rutgers Cancer Institute (New Brunswick, New Jersey)
- Dr. Edward Levine, Wake Forest Baptist Cancer Center (Winston‑Salem, North Carolina)
- Dr. Kiran Turaga, University of Chicago Medical Center (Illinois)
- Dr. Joel Baumgartner, University of California‑San Diego Moores Cancer Center (California)
- Dr. Daniel Labow, Mount Sinai Medical Center (New York, New York)
- Dr. Mecker Moller, University of Miami Sylvester Comprehensive Cancer Center (Florida)
- Dr. Kamran Idrees, Vanderbilt University‑Ingram Cancer Center (Nashville, Tennessee)
- Dr. Eugene Choi, Baylor St. Luke’s Medical Center (Houston, Texas)
Finding Surgical Treatment in the VA Health Care System
The VA health care system provides veterans access to the top cancer doctors in the world. Three VA hospitals have mesothelioma treatment programs, staffed by experienced surgeons and oncologists from nearby cancer centers.
The Houston VA program is the only one known to treat peritoneal mesothelioma with cytoreduction and HIPEC. Dr. Eugene Choi is the head peritoneal mesothelioma surgeon at the Houston VA medical center.
If you need help signing up for VA health insurance or contacting a VA hospital, please reach out to LCDR Carl Jewett. As a veterans support advocate, he can help you receive treatment.
Common Questions About Mesothelioma Cytoreduction With HIPEC
What is cytoreductive surgery with HIPEC?
Cytoreduction with HIPEC is a combination of surgery and heated chemotherapy used to treat peritoneal mesothelioma. Cytoreduction for mesothelioma involves removing the peritoneum (the thin lining surrounding the abdominal cavity) and manually resecting visible tumors. HIPEC stands for hyperthermic (heated) intraperitoneal chemotherapy. It involves bathing the abdominal cavity with liquid chemotherapy.
What is the success rate of cytoreduction with HIPEC for mesothelioma?
One study shows a five‑year survival rate of 80% after completing cytoreduction with HIPEC. By comparison, peritoneal mesothelioma patients have an average one‑year survival rate of 50%. Cytoreduction with HIPEC has an extraordinary success rate for extending the lives of peritoneal mesothelioma patients.
Is cytoreduction with HIPEC dangerous?
Any surgery has risks, with the severity ranging from minor infections to internal bleeding. Cytoreduction is no different, but safety has improved in recent years. Other potential complications include damage to any abdominal cavity organs or the body’s digestive system. In one study, 22% of patients experienced surgery‑related side effects.
How long is recovery after cytoreduction/HIPEC?
Recovery from cytoreductive surgery with HIPEC is approximately 6‑8 weeks. Most patients spend two weeks at the hospital following their surgery. Outpatient recovery — at their home or temporary residence — takes 4‑6 weeks depending on how the patient responds to the operation. Patients return to a more normal routine 3‑6 months after surgery.
How long does cytoreduction with HIPEC take?
Cytoreduction with HIPEC can last up to 14 hours. The cytoreduction part is a meticulous process where surgeons attempt to detect and remove as many tumors as they can. The extent of the disease determines how long cytoreduction takes. HIPEC has a fixed time of 60‑90 minutes.
How much does cytoreduction with HIPEC cost?
According to a report in the Annals of Surgical Oncology, the median cost of cytoreduction with HIPEC was $20,509. A New York Times article says the cost ranges from $20,000 to $100,000. Health insurance usually covers some or all of the expenses after the deductible.
Sources & Author
- Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Tufts Medical Center. Retrieved from: https://www.tuftsmedicalcenter.org/-/media/Brochures/TuftsMC/Patient%20Care%20Services/Departments%20and%20Services/Cancer%20Center/HIPEC_Final.ashx. Accessed: 07/01/2021.
- Hyperthermic Intraperitoneal Chemotherapy. MD Anderson Cancer Center. Retrieved from: https://www.mdanderson.org/treatment-options/hyperthermic-intraperitoneal-chemotherapy.html. Accessed: 07/01/2021.
- Then and now: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), a historical perspective. Journal of Gastrointestinal Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754315/. Accessed: 07/01/2021.
- Surgical Debulking of Ovarian Cancer: What Difference Does It Make? Reviews in Obstetrics and Gynecology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046749/. Accessed: 07/01/2021.
- Chemotherapy for intraperitoneal use: a review of hyperthermic intraperitoneal chemotherapy and early post-operative intraperitoneal chemotherapy. Journal of Gastrointestinal Oncology. Retrieved from: https://jgo.amegroups.com/article/view/5503/5760. Accessed: 07/01/2021.
- Peritoneal Surface Malignancy Program. Johns Hopkins Medicine. Retrieved from: https://www.hopkinsmedicine.org/surgery/specialty-areas/surgical-oncology/peritoneal-surface-malignancy-program.html. Accessed: 03/31/2021.
- HIPEC Surgery – What to Expect. Tufts Medical Center. Retrieved from: https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Cancer-Center/Clinical-Care-Services/Peritoneal-Surface-Malignancy-Program/What-to-Expect-After-HIPEC-Surgery. Accessed: 03/31/2021.
- Predictors and Outcomes of Surgery in Peritoneal Mesothelioma: An Analysis of 2000 Patients From the National Cancer Database. Annals of Surgical Oncology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32006127/. Accessed: 07/08/2020.
- CRS/HIPEC safety concerns may be outdated. MDedge. Retrieved from: https://www.mdedge.com/hematology-oncology/article/192729/gynecologic-cancer/crs/hipec-safety-concerns-may-be-outdated. Accessed: 07/29/19.
- CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative. Annals of Surgical Oncology. Retrieved from: https://link.springer.com/article/10.1245/s10434-020-09232-9. Accessed: 10/22/2020.
- Repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: review of indications and outcomes. Journal of Gastrointestinal Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754305/. Accessed: 07/08/2021.
- Laparoscopic HIPEC: A bridge between open and closed-techniques. Journal of Minimal Access Surgery. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746985/. Accessed: 07/12/2021.