Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries. Overall, EC represents the 10th most common malignancy in the United States with more than 61,000 new cases diagnosed per year. It is estimated that in 2017 EC will represent 3.6% of all new cancer cases in the United States, and projections estimate a dramatic increase in the coming years. EC is most frequently diagnosed between the age of 55 and 64, and the median age at diagnosis is 62.

Prior to the introduction of minimally invasive surgery the majority of endometrial cancer operations were abdominal hysterectomy and bilateral salpingo-oophorectomy. Further staging with pelvic and paraaortic node dissections is performed on patients with risk factors of grade of tumor, depth of invasion, size of lesion, and the presence of lymph vascular space invasion (LVSI), if detected on frozen section.

Today the majority of women with endometrial cancer are treated with robotic hysterectomy or standard laparoscopic surgery.

Abdominal hysterectomy is performed for the following indications: Uterus too large to be removed vaginally; adnexal pathology too large to remove vaginally; morbid obesity; and medical conditions that preclude the steep Trendelenburg position required for minimally invasive surgery such as pulmonary hypertension.

This chapter will highlight the Mayo Clinic algorithm for staging and treatment of endometrial cancer.

The video will demonstrate a panniculectomy prior to an abdominal hysterectomy to facilitate the operation on a morbidly obese woman (Video 9.1 ).

Endometrial biopsy via office sampling or dilation and curettage determines the preoperative diagnosis of EC.

Ultrasound is the most commonly used imaging for endometrial cancer.

The size of the uterus and the condition of the adnexa can be measured. If the uterus or the adnexa is too large to be delivered through the vagina, then the abdominal route is indicated.

Ultrasound is able to define the thickness of the tumor and invasion of the muscle. It cannot reliably determine the depth of invasion or extension to the cervix. It has 69% sensitivity and 70% specificity in determining the depth of myometrial invasion.

CT may be indicated when the ultrasound shows uterine enlargement or adnexal pathology. It is also able to detect enlarged nodes.

MRI is the most accurate imaging modality used in endometrial cancer. The accuracy for predicting depth of invasion is 83% to 92%, and helps with the assessment of cervical invasion. The diagnostic accuracy is almost 90% on T2-weighted images, 96% on postcontrast T1-weighted images, and 100% on dynamic MRI.

PET/CT may detect enlarged nodes but will not detect microscopic disease in normal sized nodes.

Because nearly all of the patients will undergo surgery and the treatment decisions will be made by the pathologic findings, the additional cost of MRI and PET/CT does not justify ordering them as a routine.

The decision for open laparotomy for treatment of endometrial cancer will be made by the size of the uterus and/or the presence of adnexal pathology.

Medical conditions will be those that would preclude a patient from having increased abdominal pressure and steep Trendelenburg position.

Morbid obesity is an indication for open procedure. Some of these patients will need a panniculectomy to facilitate exposure and improve adequacy of the hysterectomy specimen and node dissection. It may reduce postoperative wound infection since there is no overhanging adipose tissue.

If panniculectomy is planned, the patient will be counseled in the clinic and the size and placement of the incision will be discussed. The management of the umbilicus will be discussed. The options are to leave it in place, remove it, or transpose it higher in the abdominal wall. If there is a large umbilical hernia, the management of the hernia should be addressed.

Chest x-ray, peripheral blood count, renal and hepatic function profiles should be tested as routine assessment.

Preoperative mechanical bowel preparation should be avoided, but we suggest an enema performed the morning of surgery to reduce the caliber of the rectum and allow easier visualization of pelvic structures.

Prophylactic antibiotics must be administered within 30 minutes before the surgical incision.

Antithrombotic prophylaxis should be used according to international guidelines.

Hysterectomy with bilateral salpingo-oophorectomy is the cornerstone of surgical treatment for patients affected by EC. This is true in patients with stages I to IV intra-abdominal disease. The therapeutic role of lymphadenectomy (pelvic +/− paraaortic) is controversial. Randomized controlled trials fail to demonstrate a significant survival advantage for patients with grossly normal lymph nodes once an appropriate stage has been established.

Women who undergo pelvic lymphadenectomy have an attributable risk of developing lower-extremity lymphedema of 23% compared to women who undergo hysterectomy alone. For this reason, systematic complete lymphadenectomy (pelvic +/− paraaortic) should be avoided in low-risk patients.