Ovarian cystectomy in endometriomas: Combined approach

Abstract

Endometrioma is one of the most frequent adnexal masses in the premenopausal population, but the recommended treatment is still a subject of debate. Medical therapy is inefficient and can not be recommended in the management of ovarian endometriomas. The general consensus is that ovarian endometriomas larger than 4 cm should be removed, both to reduce pain and to improve spontaneous conception rates. The removal of ovarian endometriomas can be difficult, as the capsule is often densely adherent. While the surgical treatment of choice is surgical laparoscopy, for conservative treatment, the preferred method is modified combined cystectomy. Cystectomy can be destructive for the ovary, whereas ablation may be incomplete, with a greater risk of recurrence. To the best of our knowledge, the modified combined technique seems to be more efficient in the treatment of endometriomas.

Keywords: Endometrioma; combined technique; cystectomy; laparoscopy.

Figure 1

a–c. Ovarian endometriomas. Small endometrioma (a), large endometrioma and ovarian implants of endometriosis (b), bilateral endometrioma, kissing ovaries (c)

Figure 2

a, b. Laparoscopic aspiration of the endometrioma cyst. Hemosiderin staining on the ovary clued about endometrioma (a), aspiration (b)

Figure 3

a, b. A needle electrode is used to identify and create a correct cleavage plane between the cyst wall and ovarian cortex

Figure 4

a–d. Cyst wall grasped with either traumatic or atraumatic forceps and ovarian cortex handled all the time with the atraumatic one. Countertraction for the stripping (a–c). Total cystectomy (d)

Figure 5

a–d. After total stripping, sometimes meticulous hemostasis is needed. Prompt coagulation can cause diminished ovarian reserve

Figure 6

a–l. Modified combined technique for the removal of endometrioma. Cleavage plane is revealed with a fine-tip needle electrode (a, b). Countertraction is accomplished to strip the cyst wall from the ovarian cortex (c–f). When the base of the cyst is reached, a white plane is seen (g). With more traction, the tissue usually starts to tear (h). Cyst wall is coagulated using bipolar forceps and cut from the base with scissors (i–l)

Figure 7

a–d. The ovarian cortex is protected from the side effect of heat when coagulation is applied only to the base of the cyst wall in the modified combined technique

Figure 8

a–d. Hemostatic powders can be used to achieve adequate hemostasis

Figure 9

a–c. Cyst wall is taken out from the ancillary trocar

Figure 10

a–d. An endobag can be used for removing the cyst from the abdomen

Figure 11

a–f. A big mass can be introduced to the 10-mm scope’s trocar. Stripped endometrioma cyst wall is grasped (a). The grasped tissue is proceeded toward the scope, and gradually, the scope is pulled back (b, c). Then, the tissue is taken out from the main umbilical trocar (d, e). Removed endometriotic cyst mass (f)

Figure 12

a, b. Adhesion barrier gel can be applied to the field to prevent subsequent surgery-related adhesion formation

Figure 13

a–f. When necessary, a 14–16 F rubber drain can be applied after cessation of the operation. A grasper with teeth is introduced from one ancillary trocar to the others (a). When the tip of the grasper reaches the outside, this trocar is taken out, and the tip of the drain is grasped with the grasper (b, c). Then, the grasper is pulled back to introduce the drain into the pouch of Douglas (d, e). Final appearance (f)