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Hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer


Medical editor Gunnar B. Kristensen MD
Gynecological Oncologist
Oslo University Hospital

General

For confirmed endometrial cancer, the standard procedure is removal of the uterus (hysterectomy) and both ovaries (bilateral salpingo-oophorectomy, or BSO). The surgeon also checks for metastasis to other parts of the adomen and lymph nodes.

Due to the possibility of metastasis to the peritoneum and lymph nodes from serous papillary and clear cell tumors, the omentum (omentectomy) and lymph nodes are also removed. 

In tumors of low differentiation, serous papillary carcinoma, clear cell carcinomas, and carcinosarcomas, there is a high risk for metastases to lymph nodes. Lymph node staging in the pelvis and paraaortic is therefore always performed for these tumors. 

For high and moderately differentiated endometrioid tumors, the decision for lymph node staging depends on depth of invasion into the myometrium evaluated from MRI. Metastases to the adnexae or synchronous primary tumors of the adnexae are confirmed in about 20% of patients, therefore it is recommended to remove these by surgery.

This operation is preferably performed by endoscopy if the situation allows.

 

Indication

  • Suspect or confirmed endometrial cancer

Goal

  • Curative treatment and staging

Equipment

Gynecological surgery tray


Preparation

  • Enema 
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis

Implementation

  • The patient lies in the supine position.
  • An incision is made in the midline from above the symphysus to the navel, extending upward as needed. The incision should be long enough to provide adequate space to avoid rupturing of the ovaries when mobilized. 
  • Any ascites are aspirated into a syringe.
  • If there are no ascites, the abdomen is rinsed with 50 ml NaCl 9 mg/ml and aspirated into the same syringe. The aspirate is sent for cytological examination. 
  • Bookwalter's retractor should be mounted with adequate distance from the patient to allow enough space and overview. 
  • Check that the retractors are not pressing on the psoa muscle or femoral nerve to avoid compression damage, neuropathy, and paralysis in the femoral area.
  • Tip the patient by lowering the caudal end (Trendelenburg).
  • Inspect and palpate the entire abdomen for possible metastasis.
  • The ovaries and abdomen are inspected. Inspect the liver, spleen, lymph nodes, diaphragm, stomach, intestines, and omentum. 
  • Pack away the intestines with compresses moistened with NaCl 9 mg/ml. Keep these in place with retractors. 
  • Fasten a Kocher forcep on each corner of the uterus. The assisting surgeon holds the uterus.
  • Clamp and divide the round ligament on both sides.
  • Divide the bladder peritoneum.
  • Divide the peritoneum along the pelvic wall.
  • Open the extraperitoneal space along the pelvic wall.
  • Indentify the ureter and avoid it.
  • Clamp the infundibulopelvic artery which is the blood supply to the adnexa.
  • The ureter is separated from the peritoneal surface so the ureter can be pushed down before the surface is divided.
  • Dissect along the peritoneal surface to the uterus. 
  • Divide the adnexa from the uterus.
  • Push the bladder peritoneum well down to reach below the cervix.
  • Clamp the parametria closely to the cervix.
  • Place clamp diagonally and close to the vagina on the sides and cut.
  • Place Kocher forceps on the vagina immediately under the cervix to lift the vagina.
  • Use diathermy to remove the uterus and cervix immediately distal to the cervix.
  • Sew the top of the vagina.
  • Perform node staging.
  • Perform the omentectomy
  • Close the abdomen.

Follow-up

Regular postoperative observations


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