





































Laparoscopy and Laparotomy for Endometrioid Adenocarcinoma: Short‐ and Long‐Term Outcomes’ Comparison


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Laparoscopy and Laparotomy for Endometrioid Adenocarcinoma: 
Short- and Long-Term Outcomes’ Comparison 

 

Rajesh V Giri  

Professor and Head, Department of Post Graduate Studies in Shalyatantra, Muniyal Institute of Ayurveda Medical 

Science, Manipal, chanai 

 

 

 

1. Introduction 
Adenocarcinoma of the endometrium is one of the 

most common cancers seen in women's germ lines [1, 

2]. It constitutes 75–80% of all uterine malignancies 

and has the second-highest death rate worldwide [3]. 

The prevalence of obesity and subfertility also 

contribute to the increased illness load [4, 5]. 

Endometrioid adenocarcinoma is best treated 

surgically [6, 7]. A regional lymphatic basin resection 

may be done depending on the surgical result. 

Traditional laparotomy for endometrioid 

adenocarcinoma is efficient, however it comes with 

some serious drawbacks such increased intraoperative 

bleeding and extended operation times.  

 

eight to ten. A growing body of research suggests that 

endometrioid adenocarcinoma patients may benefit 

from laparoscopic surgery rather than open surgery due 

to its reduced invasiveness [11–13]. Endometrioid 

adenocarcinoma patients are advised to have 

laparoscopic surgery as their primary treatment option 

according to the 2020 NCCN Guidelines [14]. 

Laparoscopy had superior results when compared to 

the least invasive technique in a retrospective study of 

clinical and oncological outcomes for ovarian and 

cervical cancer therapy. The oncologic outcomes of 60 

ovarian cancer patients who received laparoscopic 

staging were similar to those of 120 patients who 

underwent open surgery, according to a study by 

Gallotta et al. [15]. The patients in the laparoscopy 

group had similar outcomes as those in the open 

surgery group.  

 

publication in the field of clinical practice  

method [15]. Furthermore, no statistically significant 

change in staging was seen when comparing robotic 

staging with traditional laparoscopic staging in patients 

with early-stage ovarian cancer [16]. Both laparoscopy 

and laparotomy resulted in comparable 5-year 

recurrence-free and overall survival rates for women, 

according to a prior research [17]. In a study  

Abstract— Aims. In order to compare the advantages of laparoscopy with those of laparotomy for the treatment of endometrioid 

adenocarcinoma and to draw conclusions about the relative merits of the two procedures, both in the short and long term. Methods. Six 

hundred ninety-three patients with endometrioid adenocarcinoma who had laparoscopy instead of laparotomy between 2012 and 2020 

were included in the research. The therapeutic impact of these two treatments for endometrioid cancer was evaluated by reviewing basic 

patient information, their perioperative indicators, and recurrence rates. Final product. Laparoscopy was performed on 365 endometrioid 
adenocarcinoma patients, whereas laparotomy was performed on 328 individuals. Longer operating durations, less intraoperative 

haemorrhage, and shorter postoperative hospital admissions were seen in the laparoscopic group compared to the laparotomic group. The 

laparotomic group had a much higher incidence of radical hysterectomy and less-radical hysterectomy (59/365, 16.16%) than the 

laparoscopic group (162/328, 49.39%). While the two groups did not vary substantially in terms of local recurrence, the laparotomic 
group had a much higher distant recurrence rate (15/308, 4.87%) compared to the laparoscopic group (3/351, 0.85%). There was a larger 

survival benefit in the laparoscopic group compared to the laparotomic group in both the I/II and III/IV patient subgroups (314/314, 100% 

vs. 7/242, 28.93%) and 35/37, 94.59% vs. 51/66, 77.27%). Final thoughts. Compared to patients who had laparotomic surgery, those who 

underwent laparoscopic surgery recovered more quickly and experienced a reduced risk of postoperative recurrence in the immediate 
aftermath of the procedure. The endometrioid adenocarcinoma therapy option is laparoscopic surgery, which is both safe and successful. 

 



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of early-stage endometrial cancer, Ruan et al. [18] found 

that lap-aroscopy was just as effective as laparotomy in 

terms of oncological results and surgical outcomes. 

Concerning the consequences, both immediate and long-

term, of laparoscopic and open surgery on endometrioid 

adenocarcinoma patients, there is still a great deal of 

unanswered questions.  

 

Here, we conducted a review of past work that  

examined the risks and benefits of laparoscopy and lap-

arotomy during surgery and contrasted the results for 

individuals who had these procedures.  
 

2. Patients and Methods 
Chapter 2.1: People Under Treatment. The 693 

participants in this retrospective research were recruited 

from the patient records of women who had endometrial 

cancer treatment at the Hainan Provincial People's 

Hospital in China between 2012 and 2020. Laparoscopy 

was used to treat 365 patients, whereas laparotomy was 

used to treat 328 patients. Prior to surgery, every patient 

received a diagnostic curettage and hys-teroscopy. 

Postoperatively, any further pathological diagnoses were 

solidified. In order to participate in the research, every 

single individual gave their written permission.  

 

Part 2.2: The Plan for Care 

A.2.2.1. Laparoscopic Operations. Each patient was put 

into the lithotomy position and an indwelling urine 

catheter was implanted after they had received general 

anaesthesia. The patient had an incision around 1 cm long 

made 3 cm above their navel. After the puncture was 

successfully made, the laparoscopes were inserted and 

pneumoperitoneum was established by means of carbon 

dioxide insufficiency. For the first and second incisions, 

a 5 mm incision was performed at the umbilicus level. 

Perforations were made at the right appendiceal maiotic 

point during parietal aortic lymph node dissection, and a 

third incision was made above the left anterior superior 

iliac spine for the surgery. In addition to the standard 

pelvic and abdominal exams, a cytological blood test used 

washing fluid collected from the peritoneal cavity.  

 

Methods Employed in a Total Hysterectomy (2.2.2). 

Bipolar electrocoagulation and an ultrasound knife were 

used to co-agulate and cut the uterine arterio-vein and 

infun- dibulopelvic ligaments. Simultaneously, extensive 

removal of the uterosacral ligaments around the uterus 

was carried out. A horizontal incision was made in the 

vaginal vault to facilitate the excising of the vaginal wall 

using monopolar electrocoagulation. What was the uterus  

 

taken out of the body for the purpose of a quick pathology 

analysis. Based on the extent of myometrial invasion and 

grade of tumour differentiation, lymph node dissection was 

usually conducted.  

 

Procedure for Dissecting Pelvic Lymph Nodes (2.2.3). A 

pelvic lymph node dissection was carried out, beginning at 

the medial aspect of the psoas major muscle and continuing 

to the medial aspect of the intrailiac lymph nodes, 

obturator lymph nodes, 2 cm above the common iliac 

artery, and finally, the level of the deep iliac vein on the 

foot side.  

 

Laparoscopic para-aortic lymphaticectomy procedure 

(2.2.4). Beginning at the inferior mesenteric artery and 

continuing all the way to the renal vein, lymphadenectomy 

and dissection were performed up to 2 cm above the 

bifurcation of the abdominal aorta. One kind of abdominal 

aortic lymph node has to be removed for four specific 

pathological reasons: (1) poorly differentiated type; (2) 

deep muscle layer infiltration; (3) imaging lymph node 

hypertrophy; and (4) other particular pathological type.  

 

2.2.5. Endovascular Both radical and less radical 

hysterectomy options are available. A less-or radical-

radical hysterectomy may be performed if the tumour has 

spread to the cervical stroma. Coagulation of the uterine 

artery was initiated at the point where the internal iliac 

artery and major sacral ligament met after the ureter had 

been fully exposed. The vaginal resection was around 2-3 

cm long. Transvaginal retrieval of the specimen was 

performed. The cervix is preserved with a less-radical 

hysterectomy, which mostly involves removing the uterine 

body. In addition to removing the uterus, a radical 

hysterectomy also involves cleaning the cervix, a portion 

of the upper vagina, and the lymph nodes in the pelvis.  

 

Chapter 2.2.6: Laparotomy! A transverse incision was 

created in the lower left quadrant of the abdomen, about 4 

centimetres above the umbilicus. The rest of the operation 

followed the same protocol as laparoscopic procedures.  

 

Subsequent Treatment, Section 2.2.7. Adjuvant treatments, 

such as chemotherapy, vaginal brachytherapy, and external 

pelvic irradiation, were administered to patients based on 

their clinicopathological features and risk ratings. Factors 

increasing the likelihood of this disease were advanced age 

(60+), tumour differentiation (moderate to low), depth of 

myometrial invasion, and high lymph vascular space 

invasion (LVSI).  

 

Indicators of Observation (2.2.8). Age, body mass index 

(BMI), surgical techniques, clinical stage, differentiation 



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degree, and myofascial invasion depth were all markers 

of observation.  

 

The third section is the evaluation that follows. 

Telephonic postoperative follow-up was done, and 

patients were deemed lost to follow-up if they did not 

answer the phone three times. December 30, 2020 was the 

deadline for the follow-up. In terms of  

 

Journal of Clinical Practice in the International Setting 3  

the median duration of follow-up for patients undergoing 

laparoscopy was 40 months, and it ranged from 6 to 89 

months. In the laparoscopic group, 14 cases (or 3.84% of 

the total) were lost. The median duration of follow-up for 

the laparotomic group was 42 months, and it ranged from 

7 to 91 months. Twenty cases, or 6.10 percent, were lost 

in the lapa-rotomic group.  

 

Statistical analysis in section 2.4. Using IBM SPSS 

Statistics for Windows, Version 19.0 (IBM Corp., 

Armonk, NY, USA), we conducted an analysis of 

variance on all statistical data. A component ratio is used 

to represent the values of categorical variables, and the χ2 

test was used to analyse it. The Mann-Whitney U test (for 

two groups) or one-way ANOVA (for multiple groups) 

were used to analyse the values of continuous variables, 

which are shown as the mean value ± standard deviation. 

Statistical significance was determined by a p value less 

than 0.05.  

3. Results 
3.1. Details About the Patient. The research included 693 

individuals between 2012 and 2020. The number of 

endometrioid adenocarcinoma patients treated annually at 

Hainan Provincial People's Hospital from 2013 to 2019 is 

shown in Figure 1(a). Figure 1(b) shows the distribution 

of patients with varying illness stages. Laparoscopic 

surgery was performed on 365 patients and laparotomy 

on 328 patients among those who were enrolled. Patients' 

demographics and health status were similar across the 

two groups at baseline (Table 1). Out of the 365 patients 

who underwent laparoscopic surgery, 132 had a total 

hysterectomy with bilateral adnexectomy, 174 had a total 

hysterectomy with any combination of pelvic 

lymphadenectomy, paraaortic lymphadenectomy, and 

bilateral adnexectomy, and 59 had either a conventional 

less-radical hysterectomy or a radical hysterectomy with 

any combination of pelvic lymphadenectomy, paraaortic 

lymphadenectomy, or bilateral adnexectomy. From the 

328 patients who had laparotomy, 44 had a total 

hysterectomy with bilateral adnexectomy; 132 had a total 

hysterectomy with bilateral adnexectomy and pelvic 

lymphadenectomy or paraaortic lymphadenectomy; and 

162 had either a conventional less-radical or radical 

hysterectomy with bilateral adnexectomy and pelvic 

lymphadenectomy or paraaortic lymphadenectomy. In 

terms of the method of operation, a clear distinction was 

noted.  

 

 

Section 3.2: Features of the Surgery. Table 2 displays the 

features of the surgery. those in the laparoscopic group had 

longer operating durations (p = 0.03), less intraoperative 

bleeding (p < 0.001), and shorter hospital stays after the 

procedure (p < 0.001) in comparison to those in the lapa-

rotomic group.  

 

Surgical Results Section 3.3. After that, Table 3 shows the 

results of the further comparison between the two groups' 

surgical outcomes. Relapses were less common in patients 

who had laparoscopic surgery.  

 

 

significant (p < 0.001). Seven individuals (about 1.9% of 

the total) had a recurrence after laparoscopic surgery; the 

other 349 patients are still alive and well. Thirteen 

individuals in the group that had laparotomy experienced 

recurrence. In contrast, 15 patients in the laparotomic 

group showed distant recurrence, while only 3 patients 

treated with laparoscopic surgery did so (p < 0.001). In 

addition, there was a statistically significant difference in 

the number of patients who survived following 

laparoscopic surgery (349 vs. 286, p < 0.01) compared to 

laparotomy. Furthermore, Figure 2 displayed the 3-year 

progression-free survival and 3-year overall survival, 

revealing a noteworthy disparity between the two 

categories.  

After that, we looked at the patients' disease recurrence 

data and categorised them according to the TNM stage 

(Table 4). Stage I or II disease was seen in 586 individuals. 

Out of 314 patients treated with laparoscopy, 3 had 

recurrence, and 12 cases were lost to follow-up. Relapse 

occurred in 8 out of 242 patients (3.30%) in the open 

surgery group, and 18 cases were lost to follow-up. The 

recurrence rate did not vary significantly between 

individuals with stage I and II illness (p = 0.096) in our 

study. Of the 39 patients in stages III and IV who had 

laparoscopy, 2 were not followed up with and 4 had 

recurrence. Two patients in the laparotomic group did not 

return for follow-up, and fifteen patients had recurrence 

out of sixty-eight stage III/IV cases. There was no 

statistically significant difference in the illness recurrence 

rates of III/IV patients in the two groups, according to 

Student's t-test analysis.  

4. Discussion 



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Patients diagnosed with endometrioid adenocarcinoma had 

better short- and long-term results after undergoing laparoscopic 
surgery, according to this research. Laparoscopy may provide 

some short-term benefits, such as a reduced intraoperative 

bleeding volume and a shorter hospital stay, when treating 

endometrioid adenocarcinoma, but these benefits may not last if 
the impact of tumour stage is not taken into account. Patients 

who received laparoscopy instead of laparotomy had a lower 

risk of postoperative recurrence and a higher rate of survival, 

and this was true even after adjusting for tumour stage. These 
results provide further evidence that endometrioid 

adenocarcinoma patients benefit from and have an improved 

quality of life after laparoscopy-assisted surgery.  

Laparoscopy and laparotomy have been the subject of many 

publications about their curative efficacies in the treatment of 

endometrioid adenocarcinoma [19-21]. Laparoscopy has the 

potential to reduce the length of time patients spend in the 
hospital and speed up their recovery after surgery, although both 

approaches may be equally effective in treating early-stage 

endometrial cancer [4, 6, 12, 22, 23]. In addition, some studies 

have compared the amount of time it takes to do laparoscopy 
and laparotomy, although they have come to various findings 

[24, 25]. Results from studies by Terai et al. and He et al. [26, 

27] suggest that laparoscopic surgery takes more time than 

laparotomy. Consistent with that conclusion, our research 
showed that hysteroscopy resection took an average of  

 



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 126   127  

 102  

 90  
 84 

 

 73  

 53  

II 

  

 

140 

120 

100 

80 

60 

40 

20 

0 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2013 2014 2015 2016 2017 2018 2019 
 I

 

 

(a) 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

(b) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III 

IV 

FIGuRE 1: Patient recruitment and patient stage. (a) The patients of endometrioid adenocarcinoma collected from January 2012 to July 2020. 
(b) The distribution of patients with different stages. 
 
 

more time-consuming than a laparotomy. It should be noted 

that Ghazali et al. [6] discovered that laparoscopy had a lower 
operating time compared to open surgery. In fact, a surgeon 

may be able to shorten the amount of time spent operating 
thanks to laparoscopic surgery's minimally invasive and quick 

opening of the abdomen. The contradictory findings can be due 

to a number of factors. One example is the fact that the time it 
takes several surgeons to complete the same procedure might 

range from one to two hours. Possible causes for these 

variations include operator skill, the utilisation of modern 
lumpectomy equipment, and individual variances in the 

learning curve. Consistent with other studies [26], we 
discovered a statistically significant decrease in intraoperative 

haemorrhage in the lap-aroscopic group compared to the open 

surgery group. As a result, while treating endometrioid cancer, 
laparoscopy may be preferable to laparotomy and may provide 

short-term health advantages. Less discomfort, an earlier time 

out of bed, and a faster recovery time are all benefits of the 
laparoscopic postoperative abdominal wall incision for obese 

patients. Obese people often have impaired lung function, and 
laparoscopy's belly pressure makes the airway more resistant. 

Intraoperative exposure complications, which may arise from 

the use of cumbersome surgical tools, worsen this situation 
even more. Obese individuals may need to be converted to 

open surgery due to these unforeseen complications [28]. To 
determine the optimal body mass index (BMI) for deciding 

between laparoscopy and laparotomy, further research is 

required. There were no instances of patients undergoing 
laparoscopy being converted to open surgery due to obesity, 

and no patient had a body mass index (BMI) more than 30 in 

our research.  
When it comes to treating early-stage endometrial cancer, 

laparoscopy has been shown to be both safer and more 

successful than laparotomy. In addition to a quicker recovery 

time after surgery, laparoscopy reduces the risk of illness 
recurrence and patient death [4, 29]. Few studies have 

compared the two surgical techniques for stage III and IV 
endometrial cancer therapy, but our results are consistent with 

prior publications. With a recurrence incidence of 10.8%, 39 

out of 107 patients with endometrioid adenocarcinoma stage 
III or IV who had laparoscopic therapy were included in our 

research. The recurrence rate was 22.7% in 68 individuals who 

had open surgery. The low percentage of illness recurrence 
suggests that laparoscopy could be a more beneficial 

procedure.  
 

The next step was to classify the laparoscopic and laparotomic 

recurrence sites as either local or distant. Vaginal stump and 
pelvic recurrence were considered local recurrence, but 

pulmonary and bone metastases were considered distant 

recurrence, and recurrence beyond the pelvis was characterised 
as distant recurrence. Recurrence after laparoscopic surgery 

was diagnosed as lung metastasis, according to Chu et al. [29], 
who examined the recurrence of early-stage endometrial cancer 

after two surgical modalities; however, the number of 

recurrence cases was quite small, with only two instances 
reported. According to a retrospective analysis by Palomba et 

al. [30], there was no significant difference in recurrence rates 
or recurrence locations between laparo- scopic and laparotomic 

techniques in treating 1012 patients with endometrial cancer. 

Patients with endometrial cancer stage II or III had a 
substantially greater risk of local recurrence in the laparoscopic 

group compared to the laparotomic group. In contrast to 

previous research [4, 29], our findings indicated a much higher 
recurrence rate of 39.8% for stage I patients and 37% for stage 

II patients. Our findings also showed that individuals with 

1% 

73% 

12% 

14% 

n
u
m

b
er

 o
f 

p
eo

p
le

 



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endometrial cancer at any stage were more likely to have a 
recurrence in the laparoscopic group compared to the open 

surgery group. A greater risk of distant recurrence was also 

seen in the open group. On the other hand, the rates of local 
recurrence were similar between the two groups. According to 

these results, laparoscopy is just as effective as open surgery in 

the long run. Additionally, there are academics who think that 
obese patients [32] and older patients with endometrial cancer 

[31] should be given special attention when it comes to 
minimally invasive procedures.  

Recurrence rates were higher in the laparoscopic group 

compared to the open group after various surgical techniques, 
however the difference was not statistically significant. In  



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TABlE 1: Comparison of clinicopathologic characteristics of patients. 
 

Laparoscopy group (n  365) Laparotomy group (n  328) P 

Age (years) 50.7 ± 8.5 51.3 ± 8.6 0.153 

BMI 24.4 ± 4.1 23.2 ± 4.1 0.065 

Comorbidities 

Hypertension 95 (26%) 76 (23.2%) 0.384 
Diabetes 42 (11.5%) 32 (9.8%) 0.456 

Surgical modalities   <0.001 

Total hysterectomy + bilateral adnexectomy 132 (36.2%) 44 (13.4%)  

Total hysterectomy + bilateral adnexectomy, pelvic lymphadenectomy, and/or 
paraaortic lymphadenectomy 

174 (47.7%) 122 (37.2%) 
 

Less-radical hysterectomy or radical hysterectomy + bilateral adnexectomy and    

pelvic lymphadenectomy and pelvic lymphadenectomy or paraaortic 59 (16.2%) 162 (49.4%)  

lymphadenectomy    

Degree of pathological differentiation   0.564 

Unreported 39 (10.7%) 53 (16.2%) 

G1 79 (21.6%) 76 (23.2%) 

G2 139 (38.1%) 133 (40.5%) 

G3 108 (29.6%) 66 (20.1%) 
Depth of myometrial invasion   0.885 

<1/2 252 (70.0%) 213 (64.9%)  

≥1/2 113 (30.0%) 115 (35.1%)  

TNM stage 
I 284 (77.8%) 218 (66.5%) 

0.663 

II 42 (11.5%) 42 (12.8%)  

III 36 (9.9%) 60 (18.3%)  

IV 3 (0.8%) 8 (2.4%)  

Surgical modalities   0.001 

Less-radical hysterectomy and radical hysterectomy 59 162  

Nonradical hysterectomy 306 166  

 



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P = 0.039 

3
-y

ea
r 

O
v
er

al
l 

su
rv

iv
al

 (
%

) 

  

 

TABlE 2: Comparison of surgery-related indicators between the two groups. 
 

Laparoscopy group (n  365) Laparotomy group (n  328) P 

Operation time (min) 220 ± 60 210 ± 62 0.03 

Intraoperative bleeding volume (ml) 250 ± 120 370 ± 140 <0.001 
Hospitalization postoperative days 5 ± 2 7 ± 3 <0.001 

 

TABlE 3: Comparison of recurrence and survival of two groups. 
 

 Laparoscopy group (n  365) Laparotomy group (n  328) P 

Nonrelapse 344 285 <0.01 
Relapse 7 23  

Local recurrence 4 8 0.163 

Distant recurrence 3 15 0.002 

Survival 349 286 <0.01 
Death 2 22 

100 100 

 

 

 

 

 

 

95 95 

 

 

 

 

90 

0 12 24 36 

Months 

 Laparoscopy group (n=365) 

 Laparotomy group (n=328) 

(a) 

90 

0 12 24 36 

Months 

 Laparoscopy group (n=365) 

 Laparotomy group (n=328) 

(b) 

FIGuRE 2: The 3-year survival curve. (a) 3-year progression-free survival (%). (b) 3-year overall survival (%). 

 

TABlE 4: Recurrence and death of stratificated stage in two groups. 
 

Stage I/II patients Stage III/IV patients 
 Laparoscopy group Laparotomy group P Laparoscopy group Laparotomy group P 

Relapse 3 8 0.096 4 15 0.135 

Nonrelapse 311 234  33 51  

Death 0 7 0.008 2 15 0.023 

Survival 314 235  35 51  

 
Furthermore, there was a significant difference in the frequency of 

patients receiving laparoscopic radical or subradical resection 

between the open and laparoscopic groups, suggesting that local 

recurrence is more common with laparoscopic complete 

P < 0.001 

3
-y

ea
r 

P
ro

g
re

ss
io

n
-f

re
e 

su
rv

iv
al

 (
%

) 



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hysterectomy compared to open radical hysterectomy.  

Overall, the laparoscopic group required a little more time for 
surgery to treat early-stage endometrial cancer than the laparotomic 

group; however, there was less intraoperative bleeding and shorter 

hospital stays for patients who had laparoscopic therapy. As for the 

third and fourth stages, 
 

 

patients, there was no difference between the open and laparoscopic 

groups in terms of recurrence and survival markers, indicating that 
laparoscopic surgery is a safe and effective therapeutic option that 

does not negatively affect survival results. There are a few caveats 

to this study: first, the process selection was based on the operators' 

subjective preferences; in most cases, they went with the method 
they were most comfortable with. It was common practice for 

operators to perform laparotomy on individuals with big uteruses, 

complicated estimated diseases, or advanced stages of illness. 
According to what we found,  

 

 

There were no significant changes in the patients' preoperative 
general health or pathological features, however laparotomy was 

still the preferred method for instances with a muscle layer invasion 

depth of 1/2 or more. Beginning in 2012, open surgery 

predominated over laparotomy over the first two years of the chosen 
technique for the patients included in this analysis. This was due, in 

part, to a bias in the follow-up period, which was longer for the open 

surgery group of cases. More instances went missing, and the 

majority of those cases were from earlier. To confirm the effect of 

laparoscopy on prognostic outcomes for survival in early, 

intermediate, or advanced endometrial cancer, a prospective 

randomised controlled trial involving several centres is required.  

Data Availability 

All data are available from the corresponding author upon 

reasonable request. 

Ethical Approval 

The study was approved by the Medical Ethics Committee of 

Hainan General Hospital (NO: Med-Eth-Re [2022] 283). 

This project conformed to the relevant laws and regulations, 

which was approved for implementation. 

Consent 

All the study participants signed an informed consent for 

inclusion in the study. 

Conflicts of Interest 

The authors declare that they have no conflicts of interest. 

Authors’ Contributions 

(I) Lan Hong and Genhai Zhu were responsible for study 

design/planning; (II) Shengtan Wang, Wei Li, Lang Zheng, 

Guifei Li, Lifan Shen, and Hengzhi Zhuang were responsible 

for data collection/entry; (III) Jun Liu and Xiuzhen Wang 

were responsible for data analysis/statistics; (IV) Haocheng 

Gao and Xiaohang Liu were responsible for data in- 

terpretation; (V) Lan Hong was responsible for the prepa- 

ration of the manuscript; (VI) Lan Hong and Xiuzhen Wang 

were responsible for literature analysis/search; (VII) Genhai 

Zhu was responsible for funds’ collection; (VIII) all authors 

gave the final approval of the manuscript. 

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