† These authors contributed equally.
Academic Editor: Enrique Hernandez
Background: Endometrial cancer is the most common gynaecological
malignancy in the Western world and has a strong association with obesity. The
incidence of endometrial cancer is rising and can be attributed, in part, to the
ongoing obesity epidemic. The surgical management of endometrial cancer in women
with class III obesity, defined as those with a body mass index (BMI)
In Northern Ireland (NI) there are, on average, 270 cases of endometrial cancer (EC) per year with a five-year survival of around 80% . In general, endometrial cancer is detected at an early stage, conferring good overall survival rates, but advanced stage and high-grade disease is associated with high levels of morbidity and mortality. Recent years have seen a steady increase in both incidence and mortality from endometrial cancer in NI, as in other Western populations. The age-standardised incidence has nearly doubled over the last 25 years and mortality has increased by 1.6% per year over a similar time period . This increase in mortality is of considerable concern, especially given recent evidence from North America suggesting a similar trend where the overall 5-year survival rate for high-grade endometrial cancer has been decreasing over the last four decades, dropping from over 87% (1975 to 1977) to 83% (2008 to 2014) . This increase in mortality is likely due a range of factors, but the growing obesity epidemic is a key contributor. Over 50% of new endometrial cancer cases each year are associated with obesity . Given these stark figures, considerable evolution to the treatment pathway is required for endometrial cancer patients, of which a modified surgical approach, incorporating “personalised surgery” into the management algorithm, is a key component. A minimally invasive surgical (MIS) approach carries the lowest rates of peri-operative morbidity and mortality for most women. Unfortunately, this can be technically difficult in patients with class III obesity and may result in increased complication rates. Carefully selecting such patients and incorporating panniculectomy, or apronectomy, into their surgical staging would be a “personalised surgery” approach. A panniculectomy is a surgical procedure to remove excess skin and tissue, pannus, from the lower abdomen. The pannus is sometimes referred to as an “apron”; hence the term apronectomy. The addition of this technique can significantly improve surgical access and may also have longer-term health benefits. This case series reports the initial experience of this intervention at the Northern Ireland Gynaecological Cancer Centre.
The procedure has been carefully planned and refined into the following process (see Fig. 1).
The NI approach to surgical staging incorporating
panniculectomy. (1,2,3) The patient is admitted on the day of surgery and
undergoes pre-operative marking by the Plastic Surgery team along with
pre-procedural photography. Full venous thromboembolism prophylaxis
is employed, namely graduated compression stockings, peri-operative sequential
compression devices and sub-cutaneous low molecular weight heparin for
twenty-eight days post-operatively. A general anaesthetic is administered by an
experienced anaesthetist (MS). (4) The patient is positioned in lithotomy with
trendelenberg tilt. This position allows greater surgical access to the lower
abdomen and aids with retracting bowel from the pelvis during the procedure.
(5,6) The abdominal apron is mobilised from the underlying rectus sheath using
monopolar diathermy. The umbilicus is spared. The superficial epigastric vessels
and associated perforators are preserved. Routine perioperative antibiotic
prophylaxis is administered. (7,8,9) The rectus sheath is opened in the midline
as with a standard midline laparotomy. A full assessment of the abdomen is
performed to establish disease distribution. Then, if indicated, large bowel is
carefully mobilised to allow a total omentectomy to be performed. The bowel is
then packed into the upper abdomen and a table-fixed retractor (e.g.,
The post-operative wound care management is of paramount importance to help minimise peri-operative morbidity and, consequently, ensure the patient promptly returns to baseline activities of daily living and, ultimately, receives adjuvant therapy in a timely manner. In general, wound management is a multi-disciplinary approach. The patients are managed on a gynaecology ward with experience in managing gynaecological malignancy and there are daily consults from the Plastic Surgery team and the Wound Care Specialist Nurses. The following are key parameters to the post-operative care package:
(a) PICO® dressings (Smith and Nephew) remain in place for a minimum of 7 days. There is considerable care taken on initial siting to ensure a good, consistent vacuum seal.
(b) Two drains are sited to the anterior abdominal wall. These are left in place until there is minimal output over a 24-hour period. In general, that is also around 7 days.
(c) All patients receive intra-operative antibiotic prophylaxis and do not receive post-operative prophylaxis. If there are post-operative concerns regarding infection, then antibiotics are prescribed following consultation with the Microbiology Clinical team.
(d) If wound dehiscence occurs then patients are managed with antimicrobial therapy, debridement and supportive care as indicated. The use of extended negative pressure wound therapy is on a case-by-case basis and depends on size of dehiscence and extent of any surgical debridement required.
The first four cases of combined panniculectomy and surgical staging for endometrial cancer are presented in this series (Table 1).
|Menopausal status||Postmenopausal, no HRT||Postmenopausal, never HRT||Postmenopausal, never HRT||Postmenopausal, never HRT|
|Weight||129.5 kg||138 kg||155 kg||137 kg|
|Presenting complaint||Abdominal pain, post-menopausal bleeding (PMB)||PMB||PMB||Abdominal pain, PMB|
|Diagnostics||Pipelle Biopsy: G1 EEAC||Hysteroscopic Biopsy: G3 EEAC||Hysteroscopic Biopsy: G3 EEAC||CA125: 72|
|CA125: 228 u/mL||CA125: 27||MRI A/P: Endometrial tumour, no lymphadenopathy, FIGO Stage 1A||CT A/P: 18 cm complex left adnexal mass|
|HbA1c: 66 mmol/mol||HbA1c: 42||MRI: Not feasible|
|MRI A/P: Endometrial Tumour, no lymphadenopathy, predicted FIGO Stage I. Complex ovarian mass.||MRI A/P: Endometrial tumour, no lymphadenopathy, FIGO Stage IB|
|CT A/P: 10 cm complex ovarian mass, no peritoneal disease.|
|Past medical history||Type II DM||Type II DM||Hypothyroidism||Ankylosing spondylitis|
|Ischaemic Heart Disease||Hypertension|
|Past surgical history||Nil||Tonsillectomy||Tonsillectomy||Gastric bypass surgery|
|Hiatus hernia repair|
|Smoking status||Non-smoker||Ex-smoker (stopped 20 yrs)||Ex-smoker (stopped 20 yrs)||Non-smoker|
|MDM recommendations||Panniculectomy + Staging Surgery (TAH, BSO, appendicectomy, total omentectomy)||Panniculectomy + Staging Surgery (TAH, BSO, omental biopsy)||Panniculectomy + Staging Surgery (TAH, BSO, paraumbilical hernia repair)||Panniculectomy + Staging Surgery (TAH, BSO, total omentectomy)|
The median age was 56 (range: 54–59 yrs) and the mean weight and body mass index (BMI) were 139.88 kg (range: 129.5–155) and 52.7 (range: 49.1–61) respectively. Three of four patients had a pre-operative histological diagnosis and full staging imaging (MRI pelvis and CT Chest/Abdomen/Pelvis). Pre-operative tissue diagnosis and MRI pelvis was not feasible in one patient due to previous surgery. She was managed as a malignancy based on symptoms, CT findings and elevated serum CA125 levels. All cases had a range of obesity-related co-morbidities. All cases underwent pre-operative discussion at the Northern Ireland Gynaecological Cancer Centre (NIGCC) multi-disciplinary team meeting.
All procedures were performed jointly with Gynaecological Surgical Oncological
and Plastic and Reconstructive Surgical expertise (in line with the previous
description). In the NIGCC a decision on the extent of surgical staging is taken
by the MDT following pre-operative work-up. Systematic lymphadenectomy is only
performed in patients in the following circumstances: (a) high histological
grade, (b) radiological evidence of FIGO stage
|Procedure performed||Panniculectomy with re-siting of umbilicus, TAH, BSO, total omentectomy, appendicectomy||Panniculectomy with re-siting of umbilicus, TAH, BSO, omental biopsy||Panniculectomy with re-siting of umbilicus, TAH, BSO, repair para-umbilical hernia||Panniculectomy with re-siting of umbilicus, TAH, LSO, total omentectomy|
|Pannus weight (kg)||9||8.2||6.2||14.8|
|Procedure time (mins)||201||198||241||226|
|HDU post-op||Y (24 hrs)||N||N||N|
|Perioperative Hb Drop (g/L)||19||6||35||31|
|Duration urinary catheter (days)||4||1||2||7|
|Duration drains (days)||Left: 6||Left: 2||Left: 6||Left: 6|
|Right: 2||Right: 6||Right: 5||Right: 6|
|Length of stay (post-operative days)||11||10||25||12|
|Final histopathology||Synchronous independent endometrioid adenocarcinoma of uterus and left ovary (Uterine: FIGO IA, grade 2, ovarian: FIGO IA, grade 3)||FIGO IB, Grade 2 endometrial endometrioid adenocarcinoma||FIGO IA, grade 3 endometrial endometrioid adenocarcinoma||Synchronous independent endometrioid adenocarcinoma of uterus and left ovary (Uterine: FIGO 1A, grade 1; ovarian: FIGO IIB, grade 2)|
|Adjuvant treatment||Declined||Pelvic EBRT (45 Gy, 20#)||HDR VVBT (21 Gy, 3#)||Chemotherapy (6 Cycles Carboplatin & Paclitaxel)|
|HDR VVBT (8 Gy, 2#)|
There were no major or minor intra-operative complications (see Table 3). All patients required antibiotic therapy in the initial post-operative period for pyrexia of unknown origin/suspected wound infection. One patient had a protracted length of hospital stay due to a urinary tract infection and wound healing issues requiring a return to theatre for wound debridement. One patient was readmitted for management of a superficial wound infection at day 14 postoperatively. All patients had achieved complete wound healing by the six-month follow-up review visit.
|Intra-operative complications||Nil||Nil||Nil||Ovarian cyst rupture|
|Post-operative complications||D8: Wound infection/superficial dehiscence||D3: Pyrexia of unknown origin||D1: Paralytic ileus||D3: Pyrexia of unknown origin|
|-Mx: 2/7 PO Co-Amoxiclav (patient declined further)||-Mx: 2/7 IV Teicoplanin/Metronidazole /Gentamicin; then 5/7 PO Metronidazole/Clindamycin||-Mx: Conservative||-Mx IV Tazocin|
|D5: Wound infection/superficial dehiscence||D4: Constipation|
|-Mx: 6/7 IV Flucloxacillin; then 1/7 PO Flucloxacillin||-Mx: Enema|
|D9: Non-viable umbilicus|
|-Mx: RTT, surgical debridement|
|D18: Urinary tract infection|
|-Mx: 3/7 IV Gentamicin, 7/7 PO Co-Amoxiclav|
|-D14 wound infection/superficial dehiscence|
|-Wound swab: Coliforms|
|-Mx: IV/PO co-amoxiclav, daily dressings|
|If infection:||Wound swab: Staph aureus||Wound swab: No growth Blood culture: No growth||Wound swab: Anaerobic cocci||Blood culture: No growth|
|Culture site/result||MSSU: E Coli|
|Blood culture: No growth|
Over the course of the last ten years the number of endometrial cancer-related deaths have increased by ~30% . This is in stark comparison to several other cancers where the incidence and mortality rates have plateaued or decreased in the last decade. The reasons underlying this increase are multifactorial, but the growing obesity epidemic is likely a contributing factor. It has been estimated that 60% of new endometrial cancer cases each year may be attributable to obesity . Interestingly, recent pre-clinical research has shown that adipose tissue is an important source of secreted paracrine factors, which increase endometrial cancer cell proliferation and may also enhance tumour angiogenesis .
Obesity is a significant public health threat in the UK. The prevalence rates have increased significantly over the last thirty years and rose, between 1972 and 2002, by over 300% and 500% amongst 10-year-old boys and girls, respectively . It has been projected that, if the trend continues, 60% of the UK population will be obese by 2050 .
Obesity is a well-established risk factor for the development of endometrial
cancer, also carrying one of the greatest health threats to patients
post-treatment. A standardised meta-analysis of multiple cancer types ranked the
association of obesity with cancer risk highest for endometrial cancer,
relative risk of 1.59 per 5 kg/m
The clinical management of endometrial cancer comprises surgical staging, sometimes followed by adjuvant treatment (i.e., chemotherapy, external beam radiation) dictated by a range of factors, including tumour stage, grade, cervical involvement, lymphovascular space invasion and the presence of lymph node and other extrauterine metastases. It has been shown that when MIS is employed, there is reduced post-operative complications without any impact on endometrial cancer overall survival [7-10].
However, the surgical management of endometrial cancer in women with obesity class II and III can be technically difficult. MIS is problematic in this group of patients with a high rate of conversion to laparotomy and therefore, many patients are not offered laparoscopic surgery. This high rate can be attributed to a range of factors. They commonly fit into two categories: surgical and anaesthetic. The abdominal wall visceral fat can make laparoscopic port placement difficult and can also hinder adequate movement of the laparoscopic instruments. The significant abdominal weight can cause further splinting of the diaphragm during trendelenburg tilt, a pre-requisite of laparoscopic pelvic surgery, which contributes to intra-operative ventilatory problems.
It has been shown that higher BMI results in higher peri-operative complication rates in both laparoscopy and laparotomy. The evolution of robot-assisted laparoscopic surgery carries the potential of a reduction in peri-operative complication rates but requires considerable investment in equipment and expertise by an institution to offer such a service [11,12]. It has been shown that rates of postoperative pyrexia and surgical site infection (SSI) increase with increasing BMI . In this study the mean pannus weight was 9.55 kg; it would be reasonable to assume there was a reduction in BMI post-operatively. However, one of the limitations of this study is that we do not have complete post-operative BMI data to fully assess the impact of a reduction in BMI on the rates of postoperative pyrexia and SSI in patients undergoing panniculectomy.
Laparotomy (midline or transverse suprapubic), and intra-operative conversion to laparotomy, has significant challenges with restricted surgical access resulting in longer operating times, increased intra-operative complications, increased blood loss, and failure to adequately stage or cytoreduce the disease . These patients are also at increased risk of the cluster of well-established post-operative complications; wound infection, wound dehiscence, urinary tract infection, vaginal vault collection, thrombo-embolic events, respiratory tract infection and cardiac problems. One limitation of this study is that we do not have complete data to assess
Other centres have proposed performing a panniculectomy at the start of the surgical procedure to facilitate adequate operative exposure. This technique has been shown to be safe in patients with class III obesity, with no significant increase in major peri-operative complications [15,16]. A multi-disciplinary surgical team approach further increases patient safety. A gynaecological surgical oncology team jointly working with a plastic surgery team brings together the necessary experience and skills to ensure the patient gets the best care, and consequently, the best chance of a good outcome. This does require considerable planning to ensure adequate theatre time and the presence of both specialist surgical teams at the same time. The procedure carries a high risk of wound complications and requires careful post-operative care by specialist teams to minimise this and reduce the time interval to adjuvant treatment for those women that require it. Further refinement of the surgical technique will also have an impact on peri-operative complications; it is technically possible to perform standard laparoscopic staging surgery following panniculectomy. This would reduce the trauma to the anterior abdominal wall and potentially result in more rapid wound healing.
Clearly, careful patient selection is the key for this intervention. Women with higher grade, higher stage, or synchronous malignancies are the ideal candidates. This is because those women with early stage, low grade disease can be managed conservatively using the Mirena IUS and a weight management programme, which may incorporate bariatric surgery, without impacting on cancer survival . In some circumstances these interventions may cause cancer regression but in general they allow for the cancer surgery to be delayed until the woman is at a weight where the surgical intervention carries less peri-operative risk.
The early experience in NI of panniculectomy as an adjunct to endometrial cancer staging surgery confirms the data presented in the literature. It greatly facilitated surgical exposure and allowed adequate surgical staging to be performed. Our success in this initial case series has created the potential for comparable management in future cases. In carefully selected cases, the surgical procedure can be completed safely and effectively with greater ease. Ongoing refinement of this approach in NI will result in a further reduction in perioperative morbidity.
Given the clear evidence of a linear increase in both endometrial cancer and obesity, we must be conscious that there is a real need for a major public health campaign to help reverse the UK’s obesity epidemic and, ultimately, reduce the incidence of endometrial cancer [5,6]. An intervention such as this will take time to have the desired effect so, in the interim, the addition of panniculectomy to the surgical staging of endometrial cancer may facilitate safe hysterectomy for carefully selected women with class III obesity.
JPB and MHM designed the research study. JPB, SA, GVB, HA and EFC performed the research. SM, SS, and SPD helped design the surgical methodology. DG, SM, HN and MS provided guidance on recording and interpretation of peri-operative complications. PC oversaw medical photography. WGM performed pathological analysis and advised on manuscript development. JPB, SA, IJGH and MHM analysed the data. JPB and SA wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
All subjects gave their informed consent, on regionally-approved consent forms, for inclusion in the case series and subsequent publication. Formal ethical approval was not sought as it was not deemed necessary given this was a review of clinical practice outcomes and informed consent had been sought.
We would like to express our gratitude to all those who helped us during the writing of this manuscript. Thank-you to the peer reviewers for their opinions and valuable suggestions.
This research received no external funding.
The authors declare no conflict of interest. JPB is the Review Board member of this journal, given his role as Review Board member, JPB was not involved in the peer-review of this article and has no access to information regarding its peer-review.