Minimally Invasive Versus Open CRS/HIPEC for Peritoneal Surface Malignancies: Postoperative Recovery and Long-Term Outcomes—A Systematic Review and Meta-Analysis

Background: Minimally invasive surgery (MIS) is increasingly implemented for cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies (PSM). This systematic review and meta-analysis compared minimally invasive CRS/HIPEC (M-CRS/HIPEC) and open CRS/HIPEC (O-CRS/HIPEC) in terms of perioperative, postoperative, and long-term oncological outcomes. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched for comparative studies of M-CRS/HIPEC versus O-CRS/HIPEC in adult patients. Risk of bias was assessed using the Newcastle–Ottawa Scale and RoB 2.0. Pooled relative risks (RR) for dichotomous outcomes and standardized mean differences (SMD) for continuous outcomes were calculated with 95% confidence intervals (CI). Sensitivity analyses were performed to assess the potential influence of disease burden and primary tumor heterogeneity. Results: Twenty-one studies (1 randomized controlled trial and 20 retrospective cohorts) including 1184 patients (452 M-CRS/HIPEC and 732 O-CRS/HIPEC) were analyzed. Operative time did not differ between groups (SMD = 0.195; p = 0.667). Most cytoreductive procedures were comparable, although small bowel resections were less frequent with M-CRS/HIPEC (RR = 0.537; p = 0.018). The minimally invasive approach achieved higher CC0 rates (RR = 1.053; p = 0.045), with lower blood loss (SMD = −1.838; p < 0.001) and fewer transfusions (RR = 0.588; p = 0.002). Postoperative recovery favored M-CRS/HIPEC, with earlier return of bowel function and resumption of oral intake, shorter hospital stay, fewer readmissions, and earlier chemotherapy resumption (all p < 0.05). Overall and major morbidity were reduced, while postoperative mortality and 1-, 3-, and 5-year disease-free and overall survival did not differ significantly between groups. In the disease burden-restricted sensitivity analysis, differences in small bowel resection, CC0 rate, and 90-day readmission were no longer statistically significant, whereas the main perioperative and recovery benefits persisted. No significant differences in DFS or OS were identified in the additional sensitivity analyses at the evaluable time points. Conclusions: This meta-analysis supports a selective, expertise-driven use of M-CRS/HIPEC, offering perioperative and recovery advantages without significant differences in cytoreductive adequacy or long-term outcomes in appropriately selected patients.