[Gynecological Laparoscopy] 4K Laparoscopic Endometrial Cancer Surgery

What is endometrial cancer?

Endometrial cancer is a malignant tumor originating from the endometrial glands, also known as uterine corpus cancer, and the vast majority are adenocarcinomas. It is one of the three major malignant tumors of the female genitalia. In my country, endometrial cancer is much lower than cervical cancer. However, in some Western developed countries, it is higher than cervical cancer, ranking first among gynecological malignant tumors. The highest incidence age is 58~ 61 years old, accounting for about 7% of the total number of female cancers and 20% to 30% of reproductive tract malignant tumors. In recent years, the incidence rate has been on the rise. Compared with cervical cancer, it has become close to or even exceeded. With long-term and continuous estrogen stimulation, It is related to physical factors and genetic factors such as obesity, hypertension, diabetes, infertility or infertility and menopause.

What is its cause?

Endometrial cancer is a reproductive endocrine disorder disease, mainly caused by excessive estrogen affecting the endometrium. Obesity, hypertension, diabetes, early menarche and late menopause, infertility and ovarian disease are high risk factors for endometrial cancer.

Advantages of surgery

The incidence of endometrial cancer has been on the rise in recent years, with abnormal uterine bleeding as the main symptom. Surgery is the main treatment method. 4K laparoscopic surgery is a representative of minimally invasive surgery. The surgery is displayed on a 43-inch or 55-inch large screen with ultra-high-definition pixel images, presenting a 4K ultra-clear surgical field of view to help doctors complete the surgery better. Therefore, there are advantages such as less surgical trauma, less pelvic adhesions, less intraoperative bleeding, faster postoperative recovery, less surgical infection, less abdominal wall scars, and shorter hospitalization time.

Laparoscopic radical surgery for endometrial cancer is a more difficult surgical method in the field of gynecological laparoscopic surgery, with complex technical operations and numerous equipment requirements. It places very high technical requirements on the surgeon and the team.

Choice of surgical techniques

1. The cervix is not involved (intrauterine stage I):

Extrafascial uterus + double adnexa + surgical staging (pelvic lymphadenectomy)

2. Cervical involvement (suspected stage II, pre- and post-operative coincidence rate 30%-40%):

Secondary or extensive uterus + double adnexa + surgical staging (pelvis + high paraabdominal lymph node dissection)

3. Type II endometrial cancer:

Extrafascial uterus + double adnexa + omentum (serous) + surgical staging (high lymphadenopathy)

4. Ovarian involvement (extrauterine, including ascitic fluid cytology positive stages III and IV):

Extrafascial uterus + double appendage + surgical staging (high lymph node) + tumor reduction surgery

5. Theoretically, surgical and pathological staging should be performed for patients with all stages of endometrial cancer.

6. During the operation, routine ascites cytology examination, suturing of the cervix and double fallopian tubes, and dissection of the uterus were performed to understand the depth of muscle layer infiltration and tumor-free operation.

Surgery scope and process

(1) Carry out comprehensive staged surgery according to the principle of surgical staging. The basic surgical procedure is extrafascial total hysterectomy + bilateral adnexectomy ± pelvic lymphadenectomy and para-aortic lymphadenectomy. During the operation, ascites or peritoneal lavage fluid was collected and sent for cytological examination.

(2) Sentinel lymph node biopsy combined with pathological super-staging can be chosen as an alternative to systematic lymph node dissection.

(3) For patients with endometrial serous carcinoma, clear cell carcinoma, carcinosarcoma, and undifferentiated carcinoma whose pathological examination results include endometrial curettage, the omentum should be removed.

(4) For patients who meet the indications for preserving ovarian endocrine function [histological grade G1 endometrioid adenocarcinoma, no other histological high-risk factors, tumor diameter ≤2cm; age ≤40 years old (can be relaxed in individual cases) to 45 years old)], there is an urgent need to preserve the ovaries; there is no family history of hereditary high-risk cancer; there is no abnormality in the appearance of the ovaries during the intraoperative exploration, and ovarian metastasis is ruled out; the cytology of the peritoneal wash fluid is negative, the ovaries can be preserved, and hysterectomy is recommended At the same time, both fallopian tubes were removed.

(5) Restaging surgery should be considered for intermediate- to high-risk or high-risk patients who have previously undergone incomplete staging surgery.

Recommendation: The basic surgical procedure for laparoscopic endometrial cancer surgery is extrafascial total hysterectomy + bilateral hysterectomy ± pelvic and para-aortic lymphadenectomy. Cervical metastatic tumors are a relative contraindication to laparoscopic surgery. For patients who meet the indications for preserving ovarian endocrine function, the ovaries can be preserved, but both fallopian tubes should be removed.

Main surgical steps

After entering the abdomen, first close (or ligate) the bilateral fallopian tube isthmus, fully explore the pelvic and abdominal cavity, and collect the pelvic and abdominal wash fluid for cytology examination.

Sentinel lymph node tracing and biopsy

Indications: Stage I/II low- and medium-risk endometrial cancer, excluding any high-risk factors or only one of the following high-risk factors: deep myometrial invasion, G2 or G3, stage IA non-endometrioid cancer without myometrial invasion.

Operation process: Mainly use indocyanine green (ICG) and carbon nanoparticles (CNP) as tracers. Injection at cervix 3 and 9 o'clock (single tracer) or cervix 2, 4, 8 and 10 o'clock (combined tracer) (see Figure 4). The tracer was injected slowly at a shallow injection point (depth 0.1~0.3cm) and then a deep injection point (depth 1~2cm) at a concentration of 1.25g/L. For those who use ICG, the sentinel lymph nodes are observed and identified during the operation through fluorescence camera imaging.

Note: If lymph nodes are found to be visualized during surgery, the first lymph nodes to be visualized should be removed. If sentinel lymph nodes are not detected on one side of the pelvis, systematic lymphadenectomy is required on that side. Pathological ultra-staging of sentinel lymph nodes is recommended. Stage I, low-grade, endometrial cancer without myometrial invasion does not require lymph node resection, and sentinel lymph node biopsy is not recommended.

Extrafascial total uterus + bilateral adnexectomy

(1) The surgical scope of extrafascial total hysterectomy includes the uterine body, cervix, and cervical fascia. The bladder and rectum are partially pushed away. A small amount of vaginal excision is performed in a circular manner. There is no need to expose and extrapolate the ureter. The main sacral ligament is cut close to the uterus. .

(2) Treat the bilateral appendages: open the peritoneum on the pelvic side, free the infundibular pelvic ligament, expose the ipsilateral ureter, fully coagulate (or ligate) the infundibular pelvic ligament and then cut it off. Open the anterior and posterior leaves of the ipsilateral broad ligament to the parauterine side. If the ovaries are retained and the fallopian tubes are removed, the inherent ovarian ligaments need to be coagulated and cut, and the fallopian tubes are removed along the mesosalpinx.

(3) Treatment of bilateral round ligaments: Cut the round ligaments about 2cm away from the uterine horns.

(4) Open the bladder, uterine peritoneal reflection, and push down the bladder.

(5) Treat the uterine blood vessels: Continue to push down the separation of the posterior leaf of the broad ligament to expose the uterine arteries and veins, and coagulate the uterine blood vessels at the level of the uterine isthmus.

(6) Treatment of the main sacral ligament: Expose the main sacral ligament and cut off the main sacral ligament at the starting position.

(7) Make a circular incision in the vagina, remove about 1cm of the vaginal vault, keep the cervical fascia intact, and remove the uterus completely.

(8) Suture the vaginal stump continuously or in a figure of 8.

Systemic lymph node dissection

Indications: Domestic studies show that combined ICG and nanocarbon tracing can achieve a total detection rate of 95%, but there are still some patients who cannot be successfully traced. Systemic lymph node dissection is recommended for patients who have failed to visualize sentinel lymph nodes or for stage I, medium-risk/high-risk and stage II patients. In stage I/II patients, it is found that pelvic lymph nodes are involved during surgery. Systemic pelvic lymph node dissection is not required. Only enlarged lymph nodes are removed to achieve tumor reduction and clarify whether pathological metastasis is present. However, systemic aortic dissection to the level of renal vessels is still required. Dissection of peripheral lymph nodes.

Pelvic lymphadenectomy

The lateral peritoneum is opened upward and outward along the pelvic side wall to expose the external iliac artery and vein, and lymphatic fat tissue is removed from top to bottom along the surface of the external iliac artery and vein. The upper limit reaches 2 to 3 cm above the common iliac artery, the lower limit reaches the deep circumflex iliac vein, the medial limit reaches the lateral edge of the internal iliac artery, the outer limit reaches the medial edge of the psoas major muscle, and the bottom limit reaches the surface of the obturator nerve.

Lymph node resection emphasizes the standardization of surgical operations, which can improve the effect of surgical treatment and shorten the learning curve. Pay attention to the en bloc resection of each group of lymph nodes to avoid forced traction and avulsion. During the resection process, pay attention to the anatomical relationship and enter the correct vascular sheath space. Identify the ureters, blood vessels, especially the pelvic floor venous plexus and important nerves (obturator nerve, lumbosacral trunk and even sciatic nerve) to avoid damage to surrounding tissues. Close thicker lymphatic vessels to avoid excessive damage to adipose tissue and surrounding lymphatic vessels. When removing lymph nodes, it is necessary to follow the tumor-free principle and bag them out.

Para-aortic lymphadenectomy

Use the head-down-butt-high position to push and hold the small intestine and greater omentum toward the patient's head, exposing the main abdominal aorta. When the exposure is unclear in obese patients, sutures can be used to pull and suspend the retroperitoneum to help expose the surgical field. Using the inferior mesenteric artery as a marker, open the peritoneum on the surface of the abdominal aorta longitudinally, up to the level below the transverse edge of the duodenum. It was opened to both sides along the main trunk of the abdominal aorta to expose the inferior vena cava and the lower edge of the left renal vein. To avoid damaging the ureters, the course of both ureters should be exposed freely. The lymphatic fat tissue within this range is resected sequentially, with the upper limit reaching the lower edge of the renal vein, the lower limit reaching the presacral area, and both sides reaching the left and right common iliac vessels. Care is taken to protect the nerve bundles on the surface of the abdominal aorta.

Close the abdominal cavity

Check that there are no active bleeding points in the surgical field, fully flush the abdominal and pelvic cavity with distilled water, leave a pelvic drainage tube in place, relieve pneumoperitoneum, and suture the abdominal wall of each puncture hole including the peritoneum with full-thickness suturing.

Recommendation: For stage I/II low-risk endometrial cancer, sentinel lymph node biopsy should be selected instead of systematic lymph node dissection, and the first lymph node to be visualized should be removed; if sentinel lymph nodes are not detected in one or both pelvic areas, systemic lymph node dissection should be performed . Systemic lymph node dissection should be performed for patients in stage I, medium-risk/high-risk group and stage II. For patients with stage I/II endometrial cancer with pelvic lymph node involvement, only the enlarged pelvic lymph nodes need to be removed, but systemic para-aortic lymph node dissection to the level of renal vessels is still required.

Key points of surgery

Draw boundaries, plan routes

Zhang Chi has a degree of restraint and takes advantage of the opportunity.

Know yourself and the enemy, proceed cautiously and slowly

Partial treatment, en bloc removal

Postoperative medical examination

Pathological examination: (Uterus) Well-differentiated endometrioid adenocarcinoma. A 1.5*1.2cm cauliflower-like mass was seen in the right uterine horn, with no obvious myometrial infiltration. No cancer metastasis was found in the cervical resection margin, cardinal ligament resection margin, double broad-tough resection margin, parametrial peritoneal tissue, double rectal crypt tissue, and double appendages. A total of 30 lymph nodes in each group of abdominal main, lower anterior, left and right common iliac, left and right extraskeletal, left and right intraskeletal, left and right obturator, and left and right inguinal groups were examined. No cancer metastasis was found.