Surgical Management of the Obese Patient with Endometrial Cancer
Dec 2008 – by P. DiSaia, MD
A 65 year old patient with a BMI of 55 is diagnosed with endometrial cancer. She presents now for opinions as to appropriate therapy.
The incidence of obesity is climbing at an alarming rate and secondary to multiple factors the incidence of endometrial cancer is also on the rise. The American Cancer Society estimates that in 2008, there will be in excess of 40,000 cases of endometrial cancer in the US. Every obstetrician gynecologist is faced with the morbidly obese patient who is diagnosed with endometrial cancer and the question arises as to what opinions exist for therapy. There is universal agreement that hysterectomy with bilateral salpingo-oophorectomy is minimum in the approach to this problem. Various imaging studies may be helpful in prognosticating pelvic note metastasis and other extra uterine involvement, but laparotomy remains the mainstay of therapy. FIGO has revised the staging of endometrial cancer to a surgical staging and this mandates laparotomy in most cases of obese patients.
The risks associated with surgery in morbidly obese patients are multiple. There is an increased risk of wound infection, wound adhesions, thromboembolic disease as well as increased anesthesia risk. Several techniques have been helpful in minimizing these risks and they are as follows:
The location of the incision should be determined with the patient in the standing position. One finds that a periumbilical incision (higher than the usual midline incision) is preferable since the panniculus will be reflected downward towards the toes of the patient leaving the thinner periumbilical area for the incision and optimum visualization of the pelvis. This will be further assisted using the Bookwalter retractor with the post moved lower on the table than the usual placement. The surgeon should enter the operating room several minutes prior to the commencement of the surgery to inspect the instrument table. Long instruments are essential. Good lighting is also necessary either with the use of a headlamp or a sterile fiber-optic light source for the operative field. The incision should be made leaving a minimum amount of necrotic material when cautery is used.
Following completion of the intra-abdominal surgery the incision should be closed with a "mass closure" technique. There are several mass closure techniques but the running Smead-Jones closure using a loop of delayed absorbable suture (PDS or MAXon) has proven to be very reliable. A suction drain should be left on top of the fascia emanating from a stab wound outside the incision. This along with prophylactic antibiotics significantly reduces the probability of wound abscess.
As in all surgical procedures tissues should be handled with the utmost care and sharp dissection is preferable to blunt dissection and excessive use of cautery.