RU2722566C2 - Method of combined surgical management of ia-ib endometrial cancer in patients with morbid obesity - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to oncology and gynecology. Prior to surgery, with the patient lying on his back, abdominal skin is pre-marked by umbilicus and upper anterior iliac spines. Two transverse downwardly curved lines are marked one above the other to connect said anatomical structures. Patient is placed on the operating table in the lithotomy position so that the hip and body are located in the same horizontal plane. After the surgical field is treated along the marking lines at the first stage, the skin is incised: a wedge-shaped excision of the fat flap is made in the transverse direction to the aponeurosis. Then open edges of subcutaneous fat are insulated; the flap is removed. Laparoports 10.5 cm are installed: 2 trocar with diameter of 11 mm in near-umbilicus and left iliac region, 2 trocar 5 mm – in right iliac and suprapubic areas. Patient on the operating table is moved to Trendelenburg position to 30°. Vessels of infundibular-pelvic and round ligament of uterus are coagulated and transected. Fallopian tube is coagulated. Then a mother manipulator is installed and after mobilization of uterine vessels they are ligated with subsequent colpotomy at level of arches. Uterus is transvaginally removed and vagina is closed with separate interrupted sutures.EFFECT: method enables creating a larger volume of the abdominal cavity, avoiding an excessive Trendelenburg position and performing the entire operation volume in treating the endometrial cancer of the IA-IB stage.1 cl, 3 dwg, 2 ex

Description

The field of technology.

The invention relates to medicine, namely to oncology and gynecology, in particular to the surgical treatment of endometrial cancer of the IA-IB stage in patients with morbid obesity (BMI ≥ 40 kg / m ² ).

Analogs, prototype.

The problem of treating endometrial cancer in patients with severe abdominal obesity does not cease to be relevant. Obesity can be considered as a factor in the poor prognosis, as it affects the choice of treatment plan and the implementation of its stages. Surgery in such patients and the management of the postoperative period is associated with an increased risk of complications. About 10% of women with primary endometrial cancer are considered conditionally inoperable. Patients repeatedly turn to various institutions, where they receive a refusal from the operation and are sent for radiation and hormone therapy. In the absence of alternatives, this approach of conservative treatment is considered as quite effective.

One of the alternative methods of classical surgery - hysterosectoscopy and endometrial ablation - does not have sufficient radicalism. The decrease in efficiency in invasive cancer, as well as the lack of the ability to control the state of the uterine cavity due to the formation of gross synechia or obliteration, does not allow the widespread use of this technique. Hysteroresectoscopy, apparently, can only be considered in functionally inoperable patients. (Novikova E.G., Pronin S.M. Ablation in the treatment of precancer and primary cancer of the endometrium: Medical technology. M: MNII 2005; 11-14.).

Video endoscopic techniques in the surgical treatment of endometrial cancer recently occupy a leading position, are considered as the "gold standard".

However, patients with severe obesity have significant technical limitations. On the one hand, the thickness of the abdominal wall in these patients does not allow the use of standard 10.5 cm trocars. The use of elongated 15 cm trocars complicates the manipulation due to the massiveness of the tissues of the anterior abdominal wall. Moreover, in some cases, the length of even special tools is not enough to hold them in the abdominal cavity (Berlev I.V., Ulrich E.A., Saparov A.B., Nekrasova E.A., Mikaya N.A., Urmancheeva A. F., Tsypurdeeva A.A., Laparoscopic Hysterectomy for Endometrial Cancer in Obese Patients, Obstetrics and Women's Disease Journal, Volume LXIII Issue 6/2014, 21-31; Berishvili A.I., Laktionov K.P., Kochoyan T. M, Arzumanyan A.L. et al. Laparoscopic operations in patients with uterine body cancer and metabolic syndrome. Oncology. - 2015. - T. 4. No. 3. - P. 35-38).

The use of robot-assisted surgery in patients with severe obesity is a preferable method compared to classical laparoscopy. In foreign studies, a statistically significant decrease in the duration of the operation and conversions, a larger number of lymph nodes removed was shown.

However, the need for expensive special equipment of the clinic and the training of qualified specialists limits the use of this technique.

Existing methods of surgery do not imply any effect on extremely excess fatty tissue of the abdominal wall, which is accompanied by difficulties in applying adequate pneumoperitoneum at a standard pressure of 12 mm Hg. With its mass (5-20 kg), it creates significant resistance to an increase in the volume of the abdominal cavity. Increased intra-abdominal pressure, combined with obesity and Trendelenburg position also makes it difficult to provide adequate mechanical ventilation during surgery. Increasing peak inspiratory pressure can lead to barotrauma of the lungs, and inadequate mechanical ventilation to hypoxemia and respiratory acidosis.

Particular attention should be paid to the hemodynamic effects of pneumoperitoneum and their importance, taking into account the comorbidity of this contingent of patients. It is known that there is an increase in total vascular resistance, and in response to a decrease in venous return, cardiac output decreases, which creates additional difficulties in ensuring the intraoperative safety of the patient.

Thus, objective difficulties in the treatment of this group of patients caused the search for new methods of surgical interventions in patients with endometrial cancer suffering from severe abdominal obesity.

For the first time, the idea of combining plastic surgery with gynecological operations was realized in 1994 by Cosin JA et al in 9 patients. The authors performed various types of pelvic surgery (mainly for endometrial cancer) in patients with morbid obesity. The benefits of this treatment approach were due to a reduction in the number of serious complications. At the first stage, an excision of the skin-fat flap of the abdominal wall (panniculectomy) was performed, then the main operation was performed by laparotomy. Performing simultaneous surgical intervention generally reduced the risks of surgery among this group of patients (Cosin JA, Powell JL, Donovan JT, Stueber K. The safety and efficacy of extensive abdominal panniculectomy at the time of pelvic surgery. Gynecol Oncol. 1994 Oct; 55 ( 1): 36-40).

However, the known method is highly traumatic and as video endoscopic technologies have developed, it has become possible to perform operations of equivalent volume using minimally invasive surgery.

Based on our experience, we have proposed a method for performing panniculectomy at the first stage, followed by laparoscopic surgery.

The technical result of the invention is the radical surgical treatment of endometrial cancer of the IA-IB stage with a minimal number of complications.

These technical and therapeutic results in the implementation of the invention are achieved due to the fact that as in the known method, a skin-fat flap is excised and a laparoscopic (necessary to remove) hysterectomy is performed.

A feature of the proposed method is that prior to surgery on the skin of the abdomen in the position of the patient lying on the back, preliminary marking is applied, the navel and the upper anterior iliac spine are guided, mark the two transverse downward curved lines one above the other, connecting these anatomical structures, then the patient is laid on the operating table in the lithotomy position, so that the hips and trunk are located in the same horizontal plane and after processing the surgical field along the marking lines, the skin is dissected at the first stage: the wedge-shaped excision of the fat flap is carried out in the transverse direction to the aponeurosis, then the open edges of the subcutaneous fat are isolated , the flap is removed, 10.5 cm laparoports are installed: 2 trocars with a diameter of 11 mm in the umbilical and left iliac regions, 2 trocars of 5 mm in the right iliac and suprapubic regions, the patient on the operating table is transferred to the Trendelenburg position to 30 °, then the coagul the vessels of the funnel-pelvic and round ligaments of the uterus are crossed and crossed, the fallopian tubes are coagulated, the uterine manipulator is installed and, after mobilization of the uterine vessels, they are ligated, followed by colpotomy at the level of the arches, the uterus is transvaginally removed and the vagina is sutured with separate nodal sutures. If there is evidence, a laparoscopic lymphadenectomy is performed proximally from the fork of the common iliac vessels to the vein enveloping the ilium distally, from the genitofemoral nerve, to the umbilical artery and obturator nerve from the inside and back.

The invention is illustrated by a detailed description, clinical examples and illustrations, which depict:

FIG. 1 - photo illustration of patient M., preoperative marking.

FIG. 2 - photo illustration of patient M. during surgery: a skin-fat flap was excised.

FIG. 3 - removed skin-fat flap.

The method is as follows.

Before the operation, preliminary marking is applied on the skin of the abdomen in the position of the patient lying on his back. The landmarks are the navel and upper anterior iliac spine. Mark two transverse bent downward lines one above the other, connecting these anatomical structures. The upper line, depending on the planned volume of tissue removal, can pass both below and above the navel. In the latter case, the navel is removed as part of the flap, as previously warned by the patient. Then the patient is placed on the operating table in a lithotomy position, so that the hips and trunk are located in the same horizontal plane. After thorough processing of the surgical field along the marking lines at the first stage, the skin is dissected. Wedge-shaped excision of the fat flap is carried out in the transverse direction to the aponeurosis. Then, the open edges of the subcutaneous fat are isolated using large wipes moistened with an antiseptic solution.

After removing the flap, laparoports (10.5 cm long) are installed: 2 trocars with a diameter of 11 mm in the umbilical and left iliac regions, 2 trocars of 5 mm in the right iliac and suprapubic regions. Perform a hysterectomy and, if necessary, lymphadenectomy. At the first stage, the vessels of the funnel-pelvic and round ligaments of the uterus coagulate and cross, the fallopian tubes coagulate, then the uterine manipulator is installed. After mobilization of the uterine vessels, they are ligated, followed by colpotomy at the level of the arches, transvaginal extraction of the uterus and suturing of the vagina with separate interrupted sutures. Iliac-obstructive lymphadenectomy is performed along the external iliac vessels from the fork of the common distal to the vein enveloping the ilium, the external and internal borders are the genitofemoral nerve and umbilical artery, respectively; the posterior border is the bottom of the obturator fossa with a locking nerve.

To expand the surgical field, the moderate position of Trendelenburg (up to 30 °) is used in combination with shoulder rests that prevent the patient from being disposed on the operating table.

After performing a hysterectomy, the trocars are removed from the abdominal cavity and proceed to the step-wise closure of the wound. After thorough sanitation with an antiseptic solution, two rows of interrupted sutures are applied to the subcutaneous fatty tissue. The skin is sutured with separate interrupted sutures.

In the postoperative period, broad-spectrum drugs are used as antibiotic prophylaxis against gram-positive and gram-negative flora (for example, third-generation cephalosporins). Preferred is the early activation of patients and nutrition. An ultrasound examination of the pelvis, postoperative suture and veins of the lower extremities is performed in dynamics.

A clinical example of the method.

Patient M., 70 years old, body weight 137 kg, was treated in a surgical hospital for 14 days.

Clinical diagnosis: Stage II endometrial cancer cT1aN0M0.

Concomitant pathology: Obesity III degree (BMI = 45), cyst of the left lobe of the thyroid gland. Chronic autoimmune thyroiditis with nodulation. Euthyroidism. Cerebrovascular disease, chronic cerebral ischemia. Dorsopathy is common. Bilateral gonarthrosis.

Anamnesis: against the background of 20 years of menopause, spotting from the genital tract. I went to the gynecologist at the place of residence. A separate diagnostic curettage of the uterus was performed. Low differentiated endometrial adenocarcinoma with extensive foci of necrosis.

Magnetic resonance imaging of the pelvis with contrast from 11/02/2017 The bladder is weakly filled, the walls are uneven in thickness, the contents are uniform, the lower parts of the ureters are not enlarged. The uterus in anteflexio, with clear even contours, the body is 43 × 37 mm in size, a large (32 × 27 mm) myomatous node is noted in the myometrium in the anterior wall, deforms and compresses the uterine cavity. The uterine cavity is of uneven thickness, against this background, in the region of the left uterine angle (mainly) in the cavity, tumor infiltration is 7 mm thick with a length of 20 mm to the internal pharynx, without convincing signs of spread to the myometrium. Neck with clear contours, structure without features. The ovaries are involutively changed. The walls of the rectum are not thickened, in the sigmoid colon - multiple diverticula. In the pelvic cavity free fluid is not observed. Lymph nodes are not visually changed, along the left external iliac bundle up to 13 mm in size, along the right external bundle up to 10 mm. Bones without foci of destruction. Conclusion: an MRI scan of the endometrium with no convincing signs of invasion of the myometrium against the background of large subserous fibroids.

The patient was offered, given the pronounced obesity as an alternative to surgical treatment - radiation therapy. However, the patient insisted on surgery.

Considering severe abdominal obesity and comorbidity, performing laparoscopic or laparotomic hysterectomy is associated with a high risk of serious complications. Thus, it was decided to perform the operation according to the proposed method: panniculectomy, laparoscopic hysterectomy with appendages.

At the first stage, according to the preoperative marking (Fig. 1), two transverse skin incisions 1.5 cm above the suprapubic fold and 1.5 cm above the navel, the skin fold was excised with the underlying subcutaneous fatty tissue to the aponeurosis from the right to left side regions (Fig. 2). The mass of the removed skin-fat flap was 5 kg (Fig. C). The wound surface is covered with large napkins with an antiseptic, the latter are fixed to the edges of the skin with the help of slippers. At the second stage, the abdominal cavity is punctured with a Veress needle in the umbilical region, pneumoperitoneum is 12 mm Hg. An 11 mm trocar with a laparoscope was introduced in the same area. In the right and left iliac regions and in the middle of the distance between the pubis and the navel, 2 additional 5 mm trocar and 1 trocar 12 mm were inserted. When examining the abdominal cavity, it was possible to create an abdominal volume adequate for laparoscopic surgery, without using the excessive Trendelenburg position (more than 30 degrees). After removing excess fatty tissue, the use of trocars and standard-length instruments did not have technical limitations.

Round and funnel-pelvic ligaments on both sides were coagulated and suppressed. The cervix is fixed by bullet forceps, the cervical canal is enlarged respectively No. 8.5 by the Geghar expander, the tip of the uterine manipulator is inserted into the uterine cavity. The anterior and posterior peritoneal sheets are dissected. The uterine vessels on both sides are coagulated and crossed. The uterus is cut off from the vagina at the level of the vaginal arches, evacuated from the abdominal cavity through the vagina. The vaginal stump is sutured with interrupted vicryl sutures. The trocars are removed from the abdominal cavity.

At the final stage, repeated thorough sanitation of the wound with antiseptic solutions and suturing of subcutaneous fatty tissue with separate interrupted sutures in three rows were carried out, then separate interrupted sutures were applied to the skin.

In the postoperative period, the patient is activated on the first day and the urinary catheter is removed.

In a planned histological examination, uterine neoplasia is represented by a moderately differentiated endometrioid adenocarcinoma with foci of flat cell metaplasia. The tumor is located mainly within the endometrium with the onset of invasion of the myometrium to a depth of 3 mm.

Given the histological structure and nature of the tumor, the volume of treatment, additional treatment is not shown.

Thus, in a patient with morbid obesity, an adequate volume of radical surgery was performed for initial endometrial cancer. Preventive radiation therapy in the postoperative period was not required. The patient was discharged from the hospital on the 12th day without complications. The seam healed by first intention. After discharge from the hospital, the patient was outpatiently monitoring the condition of the suture for 1 month at the surgeon in the community.

Example 2

Patient K, 58 years old, body weight 145 kg.

Clinical diagnosis: Endometrial cancer, Art. cT1aN0M0

Concomitant diseases: Obesity IV degree. Hypertension of the III stage of the III degree, the risk of MTR is high.

Anamnesis: at the gynecologist is observed irregularly. Considers herself a patient for three months, when, against the background of postmenopause, she noted the appearance of acyclic spotting from the genital tract. I went to the gynecologist at the place of residence. Performed cervical hysteroscopy and separate diagnostic curettage of the uterus. Histologically, a highly differentiated adenocarcinoma. For further examination and treatment, she turned to the MNII.

On examination:

According to ultrasound: the uterus is 44 × 35 × 38 mm in size. The myometrium structure is diffusely heterogeneous. M-echo - 11 mm, hyperechoic structure, wavy structure. The cervix is 29.5 × 30 mm in size, of a homogeneous structure, the contour is even, blood flow is not increased. Along the cervical canal, anechogenic cysts up to 10 mm in size are determined. The ovaries are not visualized, in their projection without focal zones.

Pelvic MRI: uterus in anteflexio, body size 54 × 35 mm, with clear, even contours, uterine cavity expanded, performed by tumor formation 37 × 15 mm, the intermediate zone differentiates, the myometrium is homogeneous. The cervix without pathological areas, with single cysts in the structure. The ovaries are involutively changed. The bladder is of moderate filling, the walls are not thickened, the contents are homogeneous, additional formations are not detected in the lumen, the lower parts of the ureters are not enlarged. The visualized parts of the colon (sigmoid and rectum) are not structurally changed), signs of thickening of the walls and volumetric formations were not detected. No fluid was detected in the pelvic cavity. Lymph nodes are not enlarged. No data were obtained for another focal pathology.

Given the pronounced obesity, the patient is shown to perform a simultaneous surgical intervention - removal of a skin-fat flap at the first stage.

An operation was performed - panniculectomy, laparoscopic extirpation of the uterus with appendages.

At the first stage, after preoperative marking, two transverse skin incisions were 1.5 cm above the suprapubic fold and 1.5 cm below the navel, the skin fold was excised with the underlying subcutaneous fatty tissue to the aponeurosis from the right to the left side regions. The mass of the removed skin-fat flap was 7 kg. The wound surface is covered with large napkins with an antiseptic, the latter are fixed to the edges of the skin with the help of slippers. At the second stage, the abdominal cavity is punctured with a Veress needle in the umbilical region, pneumoperitoneum is 12 mm Hg. An 11 mm trocar with a laparoscope was introduced in the same area. In the right and left iliac regions and in the middle of the distance between the pubis and the navel, 2 additional 5 mm trocar and 1 trocar 12 mm were inserted. When examining the abdominal cavity, it was possible to create an abdominal volume adequate for laparoscopic surgery, without using the excessive Trendelenburg position (more than 30 degrees). During the audit: the liver, stomach, intestinal loops, parietal and visceral peritoneum are not visually changed. The uterus is not enlarged. Right ovary 1.5 × 2 cm, Left ovary 2 × 1.5 cm, with signs of age-related atrophy. The fallopian tubes on both sides without features are soldered to the peritoneum of the Douglas space.

After removing excess fat, trocars and standard-length instruments were used.

Round and funnel-pelvic ligaments on both sides were coagulated and suppressed. The cervix is fixed by bullet forceps, the cervical canal is enlarged respectively No. 8.5 by the Geghar expander, the tip of the uterine manipulator is inserted into the uterine cavity. The anterior and posterior peritoneal sheets are dissected. The uterine vessels on both sides are coagulated and crossed. The uterus is cut off from the vagina at the level of the vaginal arches, evacuated from the abdominal cavity through the vagina. The vaginal stump is sutured with interrupted vicryl sutures. The trocars are removed from the abdominal cavity.

At the final stage, repeated thorough sanitation of the wound with antiseptic solutions and suturing of subcutaneous fatty tissue with separate interrupted sutures in three rows were carried out, then separate interrupted sutures were applied to the skin.

In the postoperative period, the patient is activated on the first day and the urinary catheter is removed. The postoperative period without complications.

Histological examination of the surgical material: moderately differentiated endometrioid adenocarcinoma of the uterine body, with foci of necrosis, with invasion of the myometrium to a thickness of 3 mm (less than 1/2 of the thickness of the myometrium). In the endometrium outside the tumor, there are signs of complex atypical hyperplasia of the endometrial glands. In the isthmic section of the uterine body, the cervix - there is no tumor growth. The vaginal portion of the cervix and cervical canal are lined with stratified squamous and single-layered cylindrical epithelium with signs of squamous metaplasia. In the region of the transformation zone in the thickness of the wall of the cervix uteri - nabotov cysts. In the right and left ovaries there are white bodies, simple cysts. Uterine tubes with paratubular cysts, foci of sclerosis of the wall. Skin flap of normal histological structure.

толщины стенки (1,5 см), отсутствие данных за неблагоприятные факторы прогноза, объем операции является радикальны, показано строгое динамическое наблюдение.Given the prevalence of the tumor process: invasion of the myometrium 3 mm - less

wall thickness (1.5 cm), lack of data for adverse prognosis factors, the volume of surgery is radical, strict dynamic observation is shown.

Using the proposed method in the clinic allows, due to the primary excision of the massive fat flap, to create a larger volume of the abdominal cavity, which avoids the excessive position of Trendelenburg and perform the entire volume of the operation in the treatment of endometrial cancer of the IA-IB stage.

Claims (2)

1. A method of performing a combined operation for endometrial cancer of the IA-IB stage in patients with morbid obesity, including excision of a skin-fat flap with subsequent hysterectomy, characterized in that prior to surgery on the skin of the abdomen in the patient’s supine position, preliminary marking is applied, with reference points are the navel and the upper anterior iliac spine, mark two transverse lines curved downwards, one above the other, connecting these anatomical structures, then the patient is placed on the operating table in a lithotomy position so that the hips and trunk are located in the same horizontal plane and after processing the surgical field along the lines markings at the first stage carry out the dissection of the skin: a wedge-shaped excision of the fat flap is carried out in the transverse direction to the aponeurosis, then the open edges of the subcutaneous fatty tissue are isolated, the flap is removed, laparoports 10.5 cm are installed: 2 trocars with a diameter of 11 mm in the umbilical and left under of the iliac region, 2 trochars of 5 mm - in the right iliac and suprapubic regions, the patient on the operating table is transferred to the Trendelenburg position up to 30 °, then the vessels of the funnel-pelvic and round ligaments of the uterus are coagulated and crossed, the uterine tubes are coagulated, then the uterine manipulator is installed and after mobilization of the uterine vessels, they are ligated, followed by colpotomy at the level of the arches, the uterus is transvaginally removed and the vagina is sutured with separate interrupted sutures. 2. The method according to p. 1, characterized in that if there is evidence, a laparoscopic lymphadenectomy is performed proximally from the fork of the common iliac vessels to the vein enveloping the ilium distally, from the genitofemoral nerve, to the umbilical artery and obturator nerve from the inside and back.

Images