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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

To evaluate the feasibility of total laparoscopic hysterectomy as the primary treatment for endometrial cancer in morbidly obese women, an audit was carried out during an 18-month period in a tertiary referral centre for gynaecological oncology. Four women who had laparoscopic surgery were compared with a similar cohort who had open surgery. The mean operating time was equivalent, without evidence of excess morbidity with the laparoscopic approach. However, inpatient stay was longer with open versus laparoscopic surgery (11.5 vs 4 days). Laparoscopic surgery is safe to use in morbidly obese women with endometrial cancer.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

Endometrial cancer is the second most common gynaecological cancer, accounting for 4% of female cancer in England and Wales. The incidence is low in women younger than 40 years but rises rapidly and plateaus after the menopause at 44 per 100,000 women.1

Obesity is a known risk factor and with the increased prevalence of clinical obesity (body mass index >30), this may have implications on the disease incidence. Women who are 9–22 kg above their body mass index have a threefold increased risk of endometrial cancer, increasing to a ninefold risk in those with an excess of 22 kg above their ideal body mass index.2

The standard approach to surgical management of early endometrial cancer is total hysterectomy and bilateral salpingo-oophorectomy by open technique. However, the laparoscopic approach has recently been applied to women with endometrial cancer with excellent outcome.3 Obese women are most likely to benefit from laparoscopic surgery as such surgery is associated with less post-operative pain, earlier ambulation, shorter hospital stays and fewer wound complications. However, although various techniques of total laparoscopic hysterectomy have been reported, there is little evidence for its use in the management of endometrial cancer in morbidly obese women.

The aim of this audit is to assess the feasibility of total laparoscopic hysterectomy in morbidly obese women as a primary treatment for endometrial cancer and to compare the results to a group of women with similar clinical characteristics who underwent open surgery.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

A prospective audit was conducted in women with a high body mass index (body mass index >30) presenting with clinical stage 1 endometrial cancer to our centre from April 2002 to November 2003 who were offered total laparoscopic hysterectomy as a primary surgical intervention. A similar number of cases were performed by open surgery in women with equal body mass indices and disease stage during the same period.

The laparoscopic procedures were performed by two accredited laparoscopic surgeons. One of these (AC) was a laparoscopic specialist accustomed to complex laparoscopic surgery, and the other was a RCOG subspeciality accredited gynaecological oncologist (AO or TM).

In all cases, central pathological review was undertaken, and all women underwent a chest radiograph and a magnetic resonance scan of the abdomen and pelvis. When these investigations confirmed localised disease, women were advised to have total hysterectomy and bilateral salpingo-oophorectomy. Routine pelvic lymph node dissection was not carried out except in women participating in the MRC ASTEC trial.4 The laparoscopic technique was offered in all cases where the laparoscopic surgeon was available. All women had bowel preparation, intra-operative prophylactic antibiotics and routine thromboprophylaxis.

Surgical techniques

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

The operations were carried out under general anaesthesia in both groups. Laparoscopy (total laparoscopic hysterectomy) was performed in the lithotomy position using videolaparoscopy equipment. A Foley catheter was inserted and remained for 24 hours post-operatively. The hysterectomy was performed using a harmonic scalpel, and the specimen was delivered vaginally.5 Laparotomy was performed through a transverse suprapubic incision followed by an extrafascial total abdominal hysterectomy and bilateral salpingo-oophorectomy.

Operating time, estimated blood loss, the rate of intra-operative and post-operative complications: conversion from laparoscopy to the classic abdominal approach, the use of blood transfusion and duration of hospital stay were compared in the two groups. Blood loss was measured in both groups by recording the contents of the fluid extraction device and weighing the swabs.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

Total laparoscopic hysterectomy was carried out in four women and four cases were managed by open surgery (Table 1). There were no conversions to open surgery. There were two women in the open surgery group who had additional lymphadenectomy carried out as part of the ASTEC study. There were two women in the open surgery group who had additional lymphadenectomy carried out as part of the ASTEC study.

Table 1.  The clinical characteristics according to operative intent. Values are presented as n, mean (range) or median [range].
CharacteristicsOpen technique (n= 4)Laparoscopic technique (n= 4)
Age (years)56.5 (37–77)58 (52–64)
Mean body mass index44.8 (30.9–49.7)45 (40.4–50.0)
Operation time142.5 (120–180)153.8 (120–180)
Lymph node dissections20
Estimated blood loss (mL)700 (500–1000)325 (100–500)
No. of blood transfusion00
Wound infections40
Length of stay11.5 [5–24]4 [2–5]

The mean operating time was very similar in the two groups: 142.5 minutes for surgery group (range 120–180 minutes) and 153.8 minutes for the laparoscopic group (range 120–180 minutes). The median duration of the post-operative hospital stay was longer in the open surgery group (11.5 days) compared with the laparoscopic group (4 days). The estimated blood loss was higher with the open surgery group (mean 700 mL vs 325 mL) although no transfusions were necessary. In all open cases, there were wound infections (one superficial wound infection, two had wound infections leading to breakdowns and one had delayed healing for up to three months). None occurred in the laparoscopic group. There was one case of bladder injury in the laparoscopic group that was recognised and repaired intra-operatively. An indwelling catheter was left in situ for two weeks with no long term sequelae.

In addition to the high body mass index, patients had co-morbidities which further complicated surgery (Table 2). Four women (two women in the open group and two women in the total laparoscopic hysterectomy group) required post-operative radiotherapy according to standard histological indications. Two cases in the open surgery group had delayed adjuvant radiotherapy treatment as a result of post-operative wound complications while no such delays occurred in the total laparoscopic hysterectomy group.

Table 2.  Details of the existing co-morbid conditions, type of surgery and histology.
CaseCo-morbid conditionsType of operationHistologyAdjuvant radiotherapy?
  1. NIDDM = non-insulin dependent diabetes; LN = lymph nodes; TAH + BSO = total abdominal hysterectomy and bilateral salpingo-oophorectomy; TLH = total laparoscopic hysterectomy.

1NilTAH + BSOComplex hyperplasiaNo
2HypercholesteraemiaTAH + BSO + LNG21BNo
3Arthritis, hypothyroidismTAH + BSO (apronectomy)G32BYes
4Congenital hip dysplasiaTAH + BSO + LNG23BYes
5Hypothyroidism, asthma, hypertensionTLHG22BYes
6NIDDMTLHG22BYes
7Hypertension, hypercholesteraemiaTLHG21BNo
8Sleep apnoea, asthma, hypertension, Jehovah's witnessTLHG21BNo

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References

Obesity is defined as an excess of adipose tissue. Overweight is defined as body mass index between 25 and 29.9. Class I obesity is a body mass index between 30 and 34.9, Class II between 35 and 39.9 and Class III a body mass index greater than 40 (1998).6 The general accepted definition of morbidly obese is a body mass index greater than 40. There was one woman in the open group who had a body mass index of 31 and the remainder had a body mass index greater than 40.

As both obesity and endometrial cancer are increasing in incidence, gynaecology oncology surgeons are likely to encounter women with a high body mass index requiring surgery. Associated co-morbidites further increase surgical and anaesthetic risks. Obesity can also impede the delivery of adjuvant radiotherapy. In this study, total laparoscopic hysterectomy was the preferred surgical option rather than laparoscopic assisted vaginal hysterectomy, as vaginal surgery has its limitations in obese women.

As far as operating time is concerned, the laparoscopic approach can take significantly longer when performed on morbidly obese women.7 In this study, there was only a 10-minute difference between the two approaches. Two cases in the open surgery group had additional lymph node dissections which naturally increased operating time. One woman had apronectomy due to limited access, again prolonging surgical time.

We recognise that our study is limited by the small number of women and by the fact that it is not a randomised controlled trial. Therefore, it could introduce selection bias in the recruitment of women. However, obesity per se did not increase the risk of laparoscopic surgery. We set out initially to test the feasibility of total laparoscopic hysterectomy in morbidly obese women as the treatment for endometrial cancer. From our preliminary data, we feel it is justified to offer total laparoscopic hysterectomy as the treatment of choice to appropriately selected women in experienced hands.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Surgical techniques
  6. Results
  7. Discussion
  8. References
  • 1
    Office for National Statistics. Cancer Trends in England and Wales 1950–1999. Studies in Medical and Population Subjects No. 1966. London: HMSO, 2001.
  • 2
    Everett E, Tamimi H, Greer B, et al. The effect of body mass index on clinical/pathologic features, surgical morbidity, and outcome in women with endometrial cancer. Gynecol Oncol 2003;90: 150157.
  • 3
    Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL. Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy? Gynecol Oncol 2000;78: 329335.
  • 4
    National Cancer Research Network Trials Portfolio, Medical Research Council, UK. ASTEC: a randomised trial of lymphadenectomy and of adjuvant external beam radiotherapy in the treatment of endometrial cancer.
  • 5
    Saridogan E, Cutner A. The use of McCartney tube during total laparoscopic hysterectomy for gender reassignment: a report of two cases. Br J Obstet Gynaecol 2004;111: 277278.
  • 6
    Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Arch Intern Med 1998;158: 18551867.
  • 7
    Ostrzenski A. Laparoscopic total abdominal hysterectomy in morbidly obese women. A pilot-phase report. J Reprod Med 1999;44: 853858.

Accepted 25 May 2004