Repeated PIPAC in advanced peritoneal metastases: technical feasibility in a real-world case series

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is increasingly used for unresectable peritoneal metastases, although repeated laparoscopic access in patients with diffuse carcinomatosis may be technically challenging. We report our institutional experience with repeated PIPAC procedures, focusing on technical feasibility and reproducibility. Between December 2024 and December 2025, 24 PIPAC procedures were performed in 10 patients with ovarian and gastrointestinal malignancies. Despite hostile abdomens, intra-abdominal adhesions, and extensive peritoneal disease, all procedures were successfully completed laparoscopically without conversion to open surgery or major postoperative complications. Trocar positioning, selective cold-scissor adhesiolysis, reuse of previous access sites, and individualized CapnoPen® orientation contributed to maintaining procedural feasibility throughout repeated treatment cycles. Treatment interruption was mainly related to disease progression and deterioration of general clinical conditions rather than technical failure. Our experience suggests that repeated PIPAC is technically feasible and reproducible even in patients with advanced peritoneal carcinomatosis when careful surgical planning and tailored laparoscopic strategies are adopted.