**2. Historic perspective and rationale for HIPEC**

Over time our view of peritoneal carcinomatosis evolved from considering it a terminal disease to considering it a form of locally advanced disease amenable to surgery which is sometimes with curative intent. The first to introduce the concept of cytoreductive surgery was Griffiths in 1975. His work shows a direct link between the radicality of the surgery and the survival of the patients [8, 9]. Five years later Spratt et al. show that hyperthermic intraperitoneal chemotherapy is feasible in peritoneal carcinomatosis [10, 11] and finally, in 1995 Sugarbaker et al. describe the technique of complete peritonectomy with an extraperitoneal approach, which in our opinion is the most suitable technique for most of the cases. He also described the combination of his technique with HIPEC [10].

If we look at the literature, we find articles clearly showing that the peritoneum in general and regions where scars exist – port sites for example are more prone to metastasis compared to solid organs and systemic chemotherapy is effective in about one third of the cases, with a complete response in only 15% of the cases [11]. Hence cytoreduction is extremely important to reduce tumor burden and HIPEC augments its efficacy by the lavage itself which, performed in a recent postoperative setting helps flush the cells resulted from manipulating bulky lesions such as is often the case. It also helps by activating heat shock proteins due to the temperature which is around 42 degrees and gives the chemotherapeutic agent a chance to act locally by putting it in direct contact with the peritoneum.
