Robotic procedure for endometrial cancer beneficial for Asians with morbid obesity

In Asian women with morbid obesity, robotic total hysterectomy with bilateral salphingo-oophorectomy (THBSO) for endometrial malignancies proves to be a reliable approach, being both safe and effective, as reported in a Singapore study.

Retrospective analysis of data from 33 patients with BMI >40 kg/m² who underwent robotic THBSO with or without pelvic lymph node dissection at the Singapore General Hospital showed that all of the procedures were successfully completed without conversion to laparotomy. A mini laparotomy was performed in four patients for the retrieval of “bulky” uterus, with sizes ranging from 276 to 525 g. [Eur J Obstet Gynecol Reprod Biol X 2024:23:100330]

The average operative time (from first incision to skin closure) was 232 min, and the average blood loss was 184 ml. Twelve patients required adhesiolysis, while six patients received additional omentectomy. None of the patients had intraoperative visceral or vascular injuries.

Immediately after the procedure, all patients were closely monitored at the high dependency unit and then transferred to general ward the following day. One patient stayed in the high dependency unit for an extra day of observation but had a complication-free recovery. There were no cases of postoperative admissions to the intensive care unit. Most patients were already walking (80 percent) and had bowel movements (72 percent) the day after surgery. Pain score on postoperative day 1 was low at 1 point.

In terms of postoperative complications, one patient was readmitted 6 days after the procedure due to ileus. Another patient was readmitted for post-site haematoma. In both patients, the events were managed conservatively.

As for survival outcomes, the 30-day mortality rate was 0 percent. One patient died 13 months after the procedure due to bowel obstruction. This patient underwent emergency bowel surgery but had a turbulent recovery complicated by sepsis and multi-organ failure. A second patient died 36 months after the procedure due to endometrial cancer recurrence.

“Gynae-oncology surgeons should actively consider robotic surgery, [which has been constantly demonstrated as safe, reliable, and effective,] as a surgical approach when evaluating morbidly obese women for the purpose of endometrial cancer surgery,” the investigators said.

Among the merits of robotic procedures are enhanced visualization and flexibility, which allow the surgeon to perform complex surgical manoeuvres such as intra-pelvic suturing and knot-tying with robotic-arm wrist movements, as well as pelvic lymph node dissection, the investigators pointed out. This is a substantial advantage, they added, given that pelvic organs are confined in a narrow space surrounded by a bony perimeter and robotic procedures allow for precise articulation of robotic arm. [J Minim Access Surg 2015;11:50-59]

Furthermore, robotic THBSO is less traumatic to the abdominal wall, the investigators continued. “The fulcrum of movements of instruments in the traditional laparoscopy surgery tends to be centred at the abdominal wall, whereas robotic [procedure] is gentle on the abdominal wall, with all of the instruments’ articulation occurring intra-abdominally.”

Of the patients included in the analysis, 30 underwent THBSO and pelvic lymph node dissection and only three received THBSO without lymph node dissection. The average age of the overall cohort was 52.9 years, and the mean BMI was 45.7 kg/m². Twenty patients were nulliparous (61 percent). The average STOP-BANG score among 27 patients who were assessed for it was 3.63, with a score of 3–4 being considered intermediate risk for sleep apnoea. Three patients were assessed with the Apnoea-Hypopnea Index score, with corresponding scores of 33, 53, and 66, placing all of them in the severe category.