Endometrial carcinoma, or “Ca Corpus” is the fourth most common cancer amongst women in Hong Kong in 2015 (Hong Kong Cancer Registry, 2017). The “Average Annual Percent Change” (AAPC) of Age-standardized Rates of common cancers over the period 2006-2015 is the second highest (+3.4%) compared with all other sites of cancer among women in Hong Kong (Hong Kong Cancer Registry, 2017). Conventional therapy for most endometrial cancer begins with a hysterectomy. Surgical staging allows for full assessment of the abdominopelvic cavity, including visualization and palpation of tissues, collection of peritoneal cytology, and removal of the pelvic and para-aortic lymph nodes. (Lachance, Darus & Rice 2008) Survival data suggest that roughly 85% to 90% of all women who are diagnosed with endometrial cancer and treated appropriately will be alive at 5 years. (Lachance, et al., 2008)
In the view of such common occurrence and the increasing trend of this disease in Hong Kong. A thorough understanding of the disease and treatment options, and to develop an all-rounded, well considered care plan is necessary for providing high quality care, promote surgical outcome and minimize post-operative complications.
1. Assess and anticipate pre-operative/pre-anesthetic needs, concerns and risks to formulate appropriate and high-quality nursing care plan.
2. Assess and anticipate intraoperative period needs, concerns and risks to formulate appropriate and high-quality nursing care plan.
3. Continuously assess and monitor the patient’s immediate post-operative period to provide suitable care for the best outcome.
Profile of the Client
Ms. Lee is a 61 years old para 0 women. She is single with positive sexual exposure. She weights 59.2kg with height of 153cm. She has diabetes mellitus, hypertension with regular medication and regular follow up at family clinic. She is allergic to unknown flu medicine and unknown type of bandage. She had a left hemithyroidectomy with thyroid nodule removed and a left superficial parotidectomy for left parotid tumor done in the past. She had her menopause in 2014 and presented with post-menopausal bleeding. She is then referred to gynecology specialist out-patient clinic on 12/10/2017. Endometrial biopsy was done on the same day and the result was grade 1 endometrioid adenocarcinoma. Trans-abdominal and trans-vaginal ultrasound determined the uterus normal size was distended by tumor for 2.36cm with 2cm right hyperechoic mass. Her diagnosis was endometrioid adenocarcinoma grade 1.
She had her Magnetic Resonance Imaging(MRI) done in private which shows no invasion to cervix, vagina, parametrium, bladder and rectum. Computed Tomography of Thorax, Abdomen and Pelvis done and the result is consistent with the diagnosis, it also shown no evidence of liver, iliac and para-aortic region lymph node metastasis.
She is then clinically admitted for TAHBSO (Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy.
The most common type of endometrial cancers are adenocarcinomas and the most common type of adenocarcinoma is endometrioid cancer (American Cancer Society, 2018). The main treatment for the patient in this case is TAHBSO, which is an operation to remove the uterus, ovaries, fallopian tubes and cervix.
For endometrial cancer, removing the uterus but not the ovaries are seldom recommended, but it may be considered in women who are premenopausal (American Cancer Society, 2018). To accurately stage the cancer, pelvic lymph node and aortic lymph node might also need to be removed.
The procedure requires general anaesthesia, and it is to be done is lithotomy position. The peritoneal cavity is entered with a midline incision. Peritoneal washing is then obtained with normal saline and to be sent for pathology. Large bowel is then dissected away from pelvic sidewall for better access, ureters are traced to avoid injury. Infundibulopelvic ligament, round ligaments, cardinal ligaments, uterosacral ligaments and uterine vessels are clamped, cut and transfixed or ligated. The bladder is then stripped away from the uterus and the vaginal vault is entered with a scalpel. The specimen is then removed by the surgeon and the vaginal vault is closed. Bilateral lymphadenectomy is then performed with the tissue between iliac vessels, obturator nerve and superior vesical vessels. The abdominal wound is then closed after haemostasis is achieved and peritoneal lavage.
The procedure requires general anaesthesia, therefore, careful pre-anaesthesia assessments and planning is required and being done by the responsible anaesthetist. The ASA score is a subjective assessment of a patient’s overall health that is based on five classes (I to V) (Daabiss, M. 2011) (Appendix I). Ms. Lee is classified as ASA II. Another commonly used tool is the Mallampati score, which identifies patients in whom the pharynx is not well visualized through the open mouth (Press, C.D. 2017) (Appendix II). Mallampati score is a relatively simple grading system which involves grading the preoperative ability to visualize the faucial pillars, soft palate and base of uvula, as a means of predicting the degree of difficulty in laryngeal exposure, which is an indication of the ease of intubation (Mallampati, S.R., Gatt, S.P., Gugino, L.D. et al., 1985). Ms. Lee is classified as Mallampati Class II.
The procedure is to be done in lithotomy position. In the lithotomy position, nerves in the legs and feet are especially at risk for injury that can lead to motor and sensory deficits (Hoffman, M. M., & Ciasulli, K. C., 2016). Sequential compression devices (SCDs) should be applied to the patient’s legs to reduce the development of DVT resulting from the venous pooling that can occur while the legs are flexed and elevated (Hoffman, et al., 2016)