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In endometrial (pre)malignancy the pre-operative work-up is primarily based on the histopathological specimen obtained. Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH + BSO) in presumed low-risk clinical stage I endometrioid endometrial carcinoma (EEC) or atypical hyperplasia (AH), is nowadays considered preferred and sufficient treatment in the Netherlands. To test the effectiveness of this pre-operative work-up, a retrospective cohort analysis was performed. Revised pre-and post-operative histopathology was compared and intra-and post-operative complications registered. In 116 consecutive patients with a preoperative diagnosis of AH or presumed stage I, grade I or II EEC planned for TLH + BSO. In 24.1 % (28/116) revised endometrial histopathology was upgraded on the definitive hysterectomy specimen. In 3.5 % (4/116) upgrading to highrisk grade III endometrial cancer (EC) was observed. In 9.9 % (8/81) of EC cases a post-operative FIGO stage IG3, II, or III was diagnosed. The major and minor short-term complication rates of TLH + BSO were 12.1 and 7.8 %. In 13.8 % (16/116) of cases conversion to laparotomy was necessary, with a significant higher percentage of obese (68.8 %) patients in the conversion versus the successful TLH + BSO group (42 %). Clinical relevant inconsistency between pre-and post-operative histopathology or FIGO stage was observed in 9.9 % of EC cases. More extensive pre-operative risk analysis of presumed low-risk EEC may be indicated, especially for the morbid obese, harboring a substantial risk for conversion to laparotomy and complications.