Laparoscopic treatment of bilateral endometriotic cysts
Epublication WebSurg.com, Feb 2015;15(02). URL: http://websurg.com/doi/lt03ennisolle002
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal. In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue. Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts. Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy. According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts. To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.