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“OUTSIDE-IN” APPROACH – EXTRAPERITONEAL LYMPH NODE DISSECTION WITH VNOTES HYSTERECTOMY BILATERAL SALPINGO-OOPHORECTOMY OMENTECTOMY FOR SURGICAL STAGING OF ENDOMETRIAL SARCOMA
Abstract
Introduction
A 65 year old female with BMI of 35 kg/m2 presented with postmenopausal bleeding for 3 months. An endometrial biopsy revealed endometrial sarcoma. Her staging CT scan showed a 6.6cm endometrial mass distending the cavity. There was no lymphadenopathy or distant metastasis. She had a history of open umbilical hernia repair with a large mesh in 2019. In view of sarcoma on the histology, she was counselled for full surgical staging including total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and omentectomy.
Description
We needed to avoid disruption of the large mesh across the umbilicus during surgical staging of this patient, as well as avoid potential bowel adhesions in the central region. We wanted to perform this using a minimally invasive approach. Therefore, we decided to adopt an “outside-in” approach whereby we performed an extraperitoneal pelvic lymph node dissection first followed by completion hysterectomy bilateral salpingo-oophorectomy and omentectomy via the VNOTES route. The surgery took a total of 206 minutes with an estimated blood loss of 200 mls. The patient recovered well post-operatively with minimal pain and no complications. She was discharged on post-operative Day 3. Final histology revealed Stage 1B low grade adenosarcoma. 14 lymph nodes were harvested with no metastasis. She was recommended for close observation and surveillance.
Conclusion/Implications
This “outside-in” approach is a safe and novel minimally invasive method of surgical staging for gynaecological cancers. It confers an advantage for technically difficult cases, such as multiple previous midline abdominal surgeries and morbid obesity.