The patient described provided written informed consent for the use and publication of medical data, operative video, and related images for educational and scientific purposes. The following protocol adheres to the human research ethics committee guidelines of Montefiore Medical Center and New York City Health and Hospitals Corporation.
Due to limitations of the available raw recording, not every step in the protocol could be fully documented in the video on this patient.
<p class="jove_t...

<ol>
	<li>Dunselman, G. A. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ESHRE+guideline:+Management+of+women+with+endometriosis.">ESHRE guideline: Management of women with endometriosis.</a> Human Reproduction. 29 (3), 400-412 (2014).</li><li>Chapron, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+deeply+infiltrating+endometriosis:+an+update.">Surgical management of deeply infiltrating endometriosis: an update.</a> Annals of the New York Academy of Sciences. 1034, 326-337 (2004).</li><li>Macer, M. L., Taylor, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+and+infertility.+A+review+of+the+pathogenesis+and+treatment+of+endometriosis-associated+infertility.">Endometriosis and infertility. A review of the pathogenesis and treatment of endometriosis-associated infertility.</a> Obstetrics and Gynecology Clinics of North America. 39 (4), 535-549 (2012).</li><li>Schenken, R. S., Asch, R. H., Williams, R. F., Hodgen, G. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Etiology+of+infertility+in+monkeys+with+endometriosis:+Measurement+of+peritoneal+fluid+prostaglandins.">Etiology of infertility in monkeys with endometriosis: Measurement of peritoneal fluid prostaglandins.</a> American Journal of Obstetrics and Gynecology. 150 (4), (1984).</li><li>Raffi, F., Metwally, M., Amer, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+of+excision+of+ovarian+endometrioma+on+ovarian+reserve:+A+systematic+review+and+meta-analysis.">The impact of excision of ovarian endometrioma on ovarian reserve: A systematic review and meta-analysis.</a> Journal of Clinical Endocrinology and Metabolism. 97 (9), 3146-3154 (2012).</li><li>Kasapoglu, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometrioma-related+reduction+in+ovarian+reserve+(ERROR):+a+prospective+longitudinal+study.">Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study.</a> Fertility and Sterility. 110 (1), 122-127 (2018).</li><li>Toya, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Moderate+and+severe+endometriosis+is+associated+with+alterations+in+the+cell+cycle+of+granulosa+cells+in+patients+undergoing+in+vitro+fertilization+and+embryo+transfer.">Moderate and severe endometriosis is associated with alterations in the cell cycle of granulosa cells in patients undergoing in vitro fertilization and embryo transfer.</a> Fertility and Sterility. 73 (2), (2000).</li><li>Pal, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+varying+stages+of+endometriosis+on+the+outcome+of+in+vitro+fertilization-embryo+transfer.">Impact of varying stages of endometriosis on the outcome of in vitro fertilization-embryo transfer.</a> Journal of Assisted Reproduction and Genetics. 15 (1), (1998).</li><li>Hornstein, M. D., Barbieri, R. L., McShane, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+previous+ovarian+surgery+on+the+follicular+response+to+ovulation+induction+in+an+in+vitro+fertilization+program.">Effects of previous ovarian surgery on the follicular response to ovulation induction in an in vitro fertilization program.</a> Journal of Reproductive Medicine for the Obstetrician and Gynecologist. 34 (4), (1989).</li><li>Morcos, R. N., Gibbons, W. E., Findley, W. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+peritoneal+fluid+on+in+vitro+cleavage+of+2-cell+mouse+embryos:+Possible+role+in+infertility+associated+with+endometriosis.">Effect of peritoneal fluid on in vitro cleavage of 2-cell mouse embryos: Possible role in infertility associated with endometriosis.</a> Fertility and Sterility. 44 (5), (1985).</li><li>Holoch, K. J., Lessey, B. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+and+infertility.">Endometriosis and infertility.</a> Clinical Obstetrics and Gynecology. 53 (2), 429-438 (2010).</li><li>Younis, J. S., Shapso, N., Fleming, R., Ben-Shlomo, I., Izhaki, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+unilateral+versus+bilateral+ovarian+endometriotic+cystectomy+on+ovarian+reserve:+A+systematic+review+and+meta-analysis.">Impact of unilateral versus bilateral ovarian endometriotic cystectomy on ovarian reserve: A systematic review and meta-analysis.</a> Human Reproduction Update. 25 (3), 375-391 (2019).</li><li>Busacca, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postsurgical+ovarian+failure+after+laparoscopic+excision+of+bilateral+endometriomas.">Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas.</a> American Journal of Obstetrics and Gynecology. 195 (2), 421-425 (2006).</li><li>Tsolakidis, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+on+ovarian+reserve+after+laparoscopic+ovarian+cystectomy+versus+three-stage+management+in+patients+with+endometriomas:+a+prospective+randomized+study.">The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study.</a> Fertility and Sterility. 94 (1), 71-77 (2010).</li><li>Tsoumpou, I., Kyrgiou, M., Gelbaya, T. A., Nardo, L. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+surgical+treatment+for+endometrioma+on+in+vitro+fertilization+outcomes:+a+systematic+review+and+meta-analysis.">The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis.</a> Fertility and Sterility. 92 (1), 75-87 (2009).</li><li>Medeiros, L. R. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopy+versus+laparotomy+for+benign+ovarian+tumour.">Laparoscopy versus laparotomy for benign ovarian tumour.</a> Cochrane Database of Systematic Reviews. (2), (2009).</li><li>Jacobson, T. Z., Duffy, J. M. N., Barlow, D., Koninckx, P. R., Garry, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+surgery+for+pelvic+pain+associated+with+endometriosis.+[Review]+[36+refs][Update+in+Cochrane+Database+Syst+Rev.+2014;8:CD001300;+PMID:+25130257],+[Update+of+Cochrane+Database+Syst+Rev.+2001;(4):CD001300;+PMID:+11687104].">Laparoscopic surgery for pelvic pain associated with endometriosis. [Review] [36 refs][Update in Cochrane Database Syst Rev. 2014;8:CD001300; PMID: 25130257], [Update of Cochrane Database Syst Rev. 2001;(4):CD001300; PMID: 11687104].</a> The Cochrane Database of Systematic Reviews. , (2009).</li><li>Carmona, F., Mart&#237;nez-Zamora, M. A., Rabanal, A., Mart&#237;nez-Rom&#225;n, S., Balasch, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+cystectomy+versus+laser+vaporization+in+the+treatment+of+ovarian+endometriomas:+A+randomized+clinical+trial+with+a+five-year+follow-up.">Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: A randomized clinical trial with a five-year follow-up.</a> Fertility and Sterility. 96 (1), (2011).</li><li>Hart, R. J., Hickey, M., Maouris, P., Buckett, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Excisional+surgery+versus+ablative+surgery+for+ovarian+endometriomata.">Excisional surgery versus ablative surgery for ovarian endometriomata.</a> Cochrane Database of Systematic Reviews. (2), (2008).</li><li>Vignali, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+excision+of+ovarian+endometriomas:+Does+it+truly+impair+ovarian+reserve?+Long+term+anti-M&#252;llerian+hormone+(AMH)+changes+after+surgery.">Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti-M&#252;llerian hormone (AMH) changes after surgery.</a> Journal of Obstetrics and Gynaecology Research. 41 (11), 1773-1778 (2015).</li><li>Revised American Society for Reproductive Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revised+American+Society+for+Reproductive+Medicine+classification+of+endometriosis.">Revised American Society for Reproductive Medicine classification of endometriosis.</a> Fertility and Sterility. 67 (5), 817-821 (1997).</li><li>Adamson, G. D., Pasta, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+fertility+index:+the+new,+validated+endometriosis+staging+system.">Endometriosis fertility index: the new, validated endometriosis staging system.</a> Fertility and Sterility. 94 (5), 1609-1615 (2010).</li><li>Endometriosis and infertility Committee. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+and+infertility:+A+committee+opinion.">Endometriosis and infertility: A committee opinion.</a> Fertility and Sterility. 98 (3), (2012).</li><li>Miller, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+endometrioma+treatment+paradigm+when+fertility+is+desired:+A+systematic+review.">The endometrioma treatment paradigm when fertility is desired: A systematic review.</a> Journal of Minimally Invasive Gynecology. 28 (3), 575-586 (2021).</li><li>Muzii, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histologic+analysis+of+specimens+from+laparoscopic+endometrioma+excision+performed+by+different+surgeons:+Does+the+surgeon+matter.">Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: Does the surgeon matter.</a> Fertility and Sterility. 95 (6), (2011).</li><li>Kotlyar, A., Gingold, J., Shue, S., Falcone, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+salpingectomy+on+ovarian+function.">The effect of salpingectomy on ovarian function.</a> Journal of Minimally Invasive Gynecology. 24 (4), 563-578 (2017).</li></ol>

Patients with diagnosed endometriosis commonly report pain or implant-related organ dysfunction, including infertility. Up to 50% of patients with endometriosis meet criteria for infertility23. Ovarian reserve, measured via AMH levels, FSH levels around menses or an antral follicle count, is used to predict patient response to gonadotropin stimulation. Surgical management of endometrioma is known to decrease ovarian reserve23. However, ovarian reserve continues to decline i...

Endometriosis is a chronic inflammatory condition defined by ectopic endometrial tissue1. Patients with endometriosis commonly present with pain-related complaints and organ dysfunction related to the site of ectopic implantation, which may be anywhere in the body though is typically within the pelvis2,3. Ovarian endometrioma, in which a cyst of endometriosis forms within the ovary, contributes to subfertility by multiple means, including depletion of the ovarian follicle pool, promoting an inflammatory environment, progesterone resistance, and impaired ovum release and capture4. Affected patients frequently have diminished ovarian reserve upon presentation, and the follicle pool is further depleted following surgery5,6. Cyclic bleeding in sites with ectopic endometrial tissue leads to inflammation and significant adhesions, which may impair ovum pick-up and transport, fertilization, and embryo passage7,8,9. The abnormal inflammatory environment may also impair folliculogenesis and early embryonic development10,11.
At a practical surgical level, the resultant adhesions frequently obliterate normally avascular surgical planes, placing patients at elevated risk of prolonged operative times, blood loss, and surgical injury. Surgical management of patients desiring future fertility presents additional challenges, most notably risk of iatrogenic damage to the tubes and ovaries, compromising tubal patency or ovarian reserve12,13,14. However, surgical resection of endometriosis also presents a unique opportunity to potentially diagnose, evaluate, and treat identified lesions, including optimizing fertility15.
We detail our approach to the treatment of ovarian endometriomas in patients desiring future fertility. We strongly favor a laparoscopic approach over laparotomy for enhanced post-operative results, including less pain, shorter hospital stay, and quicker recovery16. This protocol prioritizes excision of ovarian endometrioma over drainage and ablation as it provides a more favorable outcome with respect to cyst recurrence, pain recurrence, and spontaneous pregnancies17,18,19,20. Additionally, it allows for the specimen retrieval for histology. We excise ovarian endometrioma via a stripping technique with limited electrosurgical energy application. Nonetheless, many specialized tools have been described for the management of ovarian endometrioma and multiple acceptable surgical approaches exist for patients desiring future fertility. Regardless of any specific technique employed, the considerations and surgical principles described in this protocol are applicable to all patients with endometriosis desiring fertility-optimizing surgery.
The protocol described below was employed for the care of a 32-year-old woman with chronic pelvic pain and histologically proven endometriosis identified during a prior laparoscopy, during which endometriosis was incompletely resected. She endorsed pain refractory to the first-line medical management and was interested in future fertility, although had not actively attempted spontaneous conception. She was deemed a candidate for minimally invasive surgical resection and underwent an exam under anesthesia, diagnostic laparoscopy, lysis of adhesions, ovarian cystectomy, chromopertubation, and salpingectomy. Her surgery and recovery were uncomplicated.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Basic laparoscopy</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>1L bag 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>1-10% povidone-iodine</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>2% chlorhexidine gluconate in 70% isopropyl alcohol for skin</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>4% chlorhexidine gluconate</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>5mm laparoscopic trocar and sleeve x 3</td>
			<td>Covidien</td>
			<td>ONB5STF</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>12mm laparoscopic trocar and sleeve</td>
			<td>Covidien</td>
			<td>ONB12STF</td>
			<td>Diagnostic laparoscopy and larger size facilitates specimen retrieval bag</td>
		</tr>
		<tr>
			<td>CO2 insufflator</td>
			<td>Stryker</td>
			<td>620-040-504</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>CO2 insufflator tubing</td>
			<td>Stryker</td>
			<td>620-030-201</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Electrosurgical generator</td>
			<td>Covidien</td>
			<td>VLFT10GEN</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Foley kit and urometer bag</td>
			<td>Bard</td>
			<td>153214</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic scope, 5mm 0 degree</td>
			<td>Olympus</td>
			<td>WA4KL500</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic scope, 5mm 30 degree</td>
			<td>Olympus</td>
			<td>WA4KL530</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic suction irrigation pool tip</td>
			<td>Stryker</td>
			<td>250-070-406</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>StrykeFlow II suction irrigator</td>
			<td>Stryker</td>
			<td>250-070-500</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Suction tubing</td>
			<td>Stryker</td>
			<td>250-070-403</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Suction/vacuum source</td>
			<td></td>
			<td></td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Cystectomy and Salpingectomy</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mm tissue retrieval bag</td>
			<td>Covidien</td>
			<td>173050G</td>
			<td>Specimen retrieval bag to be used in 12mm laparoscopic trocar site</td>
		</tr>
		<tr>
			<td>Atraumatic laparoscopic bowel graspers</td>
			<td>Stryker</td>
			<td>250-080-319</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Bipolar Cord</td>
			<td>Stryker</td>
			<td>250-040-016</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Endopeanut laparoscopic retractor</td>
			<td>Covidien</td>
			<td>173019</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Harmonic ACE +7 ultrasonic shears</td>
			<td>Ethicon</td>
			<td>HARH23</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Laparoscopic bipolar grasping forceps</td>
			<td>Karl Storz</td>
			<td>38951 MD</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Laparoscopic curved Metzenbaum scissors</td>
			<td>Stryker</td>
			<td>250-080-267</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Ultrasonic generator unit</td>
			<td>Ethicon</td>
			<td>GEN11</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Vasopressin solution (20 units in 50 to 100cc of injectable saline)</td>
			<td></td>
			<td></td>
			<td>Cystectomy</td>
		</tr>
		<tr>
			<td>Chromopertubation</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mg methylene blue in 150mL 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>Pigmented solution for chromopertubation</td>
		</tr>
		<tr>
			<td>ZUMI uterine manipulator/injector</td>
			<td>Cooper Surgical</td>
			<td>ZSI1151</td>
			<td>Chromopertubation, diagnostic laparoscopy, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Hemostatic agents</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Arista absorbable hemostatic particles 3g</td>
			<td>Bard Davol</td>
			<td>SM0002-USA</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Floseal gelatin thrombin matrix 5ml</td>
			<td>Baxter</td>
			<td>ADS201844</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mm tissue retrieval bag</td>
			<td>Covidien</td>
			<td>173050G</td>
			<td></td>
		</tr>
		<tr>
			<td>Arista absorbable hemostatic particles 3g</td>
			<td>Bard Davol</td>
			<td>SM0002-USA</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Atraumatic laparoscopic bowel graspers</td>
			<td>Stryker</td>
			<td>250-080-319</td>
			<td></td>
		</tr>
		<tr>
			<td>Endopeanut laparoscopic retractor</td>
			<td>Covidien</td>
			<td>173019</td>
			<td></td>
		</tr>
		<tr>
			<td>Floseal gelatin thrombin matrix 5ml</td>
			<td>Baxter</td>
			<td>ADS201844</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Harmonic ACE +7 ultrasonic shears</td>
			<td>Ethicon</td>
			<td>HARH23</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic bipolar grasping forceps</td>
			<td>Karl Storz</td>
			<td>38951 MD</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic curved Metzenbaum scissors</td>
			<td>Stryker</td>
			<td>250-080-267</td>
			<td></td>
		</tr>
		<tr>
			<td>Methylene blue 10mg in 150mL 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>For chromopertubation</td>
		</tr>
		<tr>
			<td>ZUMI uterine manipulator/injector</td>
			<td>Cooper Surgical</td>
			<td>ZSI1151</td>
			<td>For uterine manipulation and chromopertubation</td>
		</tr>
	</tbody>
</table>

surgical techniques to optimize ovarian reserve during laparoscopic cystectomy for ovarian endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

Table 1 shows results of our patient example. Total operation time was 251 min from anesthetic induction to extubation, with an estimated blood loss of 200 mL. The recovery period was uncomplicated. As she desired future pregnancy remote from the time of surgery, she began oral contraceptives. Histopathological examination revealed a right hydrosalpinx with paratubal cyst, bilateral endometriomas (4.5 cm and 3.7 cm), and ovarian tissue.
The surgery utilized a combination of fe...

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Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Surgical techniques to optimize ovarian reserve during laparoscopic cystectomy for ovarian endometrioma. This protocol describes several fertility-sparing techniques performed during cystectomy for ovarian endometrioma. These techniques demonstrate ways to limit surgical damage to the ovarian tissue, allow for a full evaluation of the pelvic anatomy, and identify and treat genital tract pathology.The following is demonstrated with a patient example obtained with written informed consent for the use and publication of medical data, video, and related images for educational and scientific purposes. This protocol follows guidelines of our institution's Human Research Ethics Committee. We will discuss the case of a 32-year-old woman desiring future fertility.She has biopsy-proven endometriosis from a prior diagnostic procedure, which left her disease incompletely resected and resulted in medically refractory pain. She was a candidate for minimally invasive approach to resect endometriosis. Step one, the preoperative evaluation.Every patient should complete an in-person consultation to obtain a thorough history and physical exam. Additionally, the patient should be screened to determine which preoperative imaging study may be helpful. Transvaginal ultrasonography is a standard imaging modality, as it usually provides adequate visualization and resolution of the uterus, posterior cul-de-sac, right adnexa, and left adnexa.Inpatients with endometriosis, consider obtaining an MRI to evaluate for the presence of adnexal pathology, adenomyosis, hydronephrosis, and evidence of deep infiltrating endometriosis, which may require further surgical planning. These findings may be reliably assessed with ultrasound alone in most patients with an experienced radiologist and aid of bowel prep. Determine whether the patient is an appropriate surgical candidate.Indications for cystectomy include size greater than four centimeters with pain or infertility or size less than four centimeters with medically refractory pain or concern for follicle count or accessibility during assisted reproduction. The patient must have no other surgical contraindications. This patient had lesions up to five centimeters plus medically refractory pain and was thus a candidate for cystectomy.The patient must be informed about the potential risks and benefits of the proposed surgery. A more complete resection risks further decline in ovarian reserve. The patient should be informed of management options regarding abnormal salpinges.In cases of deep infiltrating endometriosis, significant surgical morbidity and need for bowel resection must be addressed. Following an informed consent discussion, this patient elects for a diagnostic laparoscopy, excision of endometriosis, cystectomy, chromopertubation, and possibly salpingectomy. Now we begin our demonstration of indicated operative steps during surgeries for endometrioma resection with discussion of the exam under anesthesia and diagnostic laparoscopy.After an exam under anesthesia, create a pneumoperitoneum with standard techniques, with entry either periumbilically or at Palmer's point, as denoted by U and P on the figure. Place at least two additional lower abdominal ports, as shown here in the figure. First, perform a diagnostic laparoscopy to exclude surgical injury and to identify anatomy, adhesions, and possible endometriosis implants in the peritoneal cavity.Place a uterine manipulator and utilize steep Trendelenburg position to optimize visualization of pelvic structures. Systematically evaluate all pelvic structures and spaces. For diagnostic purposes, biopsy all possible endometriotic implants.Endometriosis can be scored to reliably describe the patient's condition using either the Revised American Society for Reproductive Medicine System or the Endometriosis Fertility Index, which is most appropriate for predicting fertility outcomes. Often, adhesiolysis is required for adequate exposure. Lysis of adhesions allow for adequate tissue handling.Once port placement is optimal, prepared to dissect adhesions to expose the adnexa. Divide the kissing ovaries and lyse tubal adhesions. Start with blunt dissection from the healthy tissue proximally, working towards dense adhesions and abnormal anatomy.Triangulate applied forces to allow for efficient dissection. Atraumatic graspers can apply traction to sensitive tissues, while the suction irrigator can push, sweep, hydrodissect, and aspirate for enhanced visualization. Continue along a dissection plane until it can no longer be easily developed bluntly.Use scissors or energy devices like ultrasonic shears to dissect dense adhesions. Ensure full tubal length is freed from adhesions, including fimbriae. When working in proximity to major structures, the surgeon must be prepared to perform retroperitoneal dissection and ureterolysis for safe identification of anatomy prior to dividing adherent structures.The next step is to evaluate for genital tract patency. We demonstrate this with chromopertubation. Through the uterine manipulator, inject dilute methylene blue.Evaluate laparoscopically for distension of the fallopian tube and spillage of dye from the fimbriae. When tubal patency is not demonstrated, ensure satisfactory fimbriolysis. Next, use atraumatic graspers to occlude the patent tube proximally.This will favor flow of dye through the contralateral side. Finally, the surgeon can replace the uterine manipulator for a dedicated catheter commonly used during hysterosalpingogram to reattempt distension. After tubal pathology is identified and evaluated, consider removal of diseased portions if consistent with the surgical plan.Here, we perform a partial right salpingectomy after identification of the infundibulopelvic ligament, labeled with a star. Exposing the tube with graspers, start the dissection of the tubal lumen from the mesosalpinx at its fimbriated end. Limit the amount of mesosalpinx excise to preserve anastomotic vascular connections that supply ovarian tissue.Reaching the isthmus, transect across the full tubal lumen to complete this step. The patient should be informed of her tubal status, as well as the presence of any remaining tubal tissue after surgery. The next step is cystectomy for ovarian endometrioma.Divide remaining adhesions to free the ovary. Any disruption of the endometrioma cyst wall will yield chocolate-colored fluid. Elevate the ovary with graspers to facilitate exposure of the lesion.Incise the thinnest portion of ovarian cortex to expose the cyst wall. In this example, the endometrioma is then drained to identify the cleavage plane. Using traction and counter traction, separate the cyst wall from normal ovarian parenchyma.This step is difficult, as adherent cyst wall is often removed with normal ovarian tissue. Efficient dissection requires close placement of graspers with applied force perpendicular to the dissection plane. This will avoid tearing.In this example, optimal technique would have also used graspers placed on the ovarian side, closest to the dissection plane. After complete excision, assess the operative bed for hemostasis. Use copious irrigation and aspiration to remove hemoperitoneum and evaluate for active bleeding.Start by observing the ovary for one to three minutes as the endogenous coagulation cascade is activated. If bleeding continues, try topical hemostatic agents. Consider suturing for actively bleeding vascular lesions.In our patient's example, we applied focused ultrasonic energy as we were assured of a safe margin away from genitourinary and gastrointestinal structures. Surgeons should minimize energy application to sensitive tissues, such as the ovary and its related blood supply. Consider sources with the least potential for lateral thermal spread, such as laser vaporization with carbon dioxide, ultrasonic energy, followed by bipolar and lastly monopolar electrosurgery, which has the greatest potential for collateral damage and inadvertent injury.Once hemostasis is assured, gather all specimens for retrieval into a bag to reduce the risk of port site endometriosis. Specimen removal should be under direct visualization. Address remaining sites of endometriosis.Specific approaches and techniques for this vary, depending on the site of implantation. Peritoneal implants can be biopsied and stripped, while removal of deep disease that cannot be shaved may require coordination with specialists, such as urologic or colorectal surgeons. Confirm hemostasis at the operative bed.Fascial defects larger than one centimeter are closed, followed by skin closure. The total operative time was 251 minutes. There was a total estimated blood loss of 200 cc's.The recovery period was uncomplicated and histopathological examination revealed a right hydrosalpinx with paratubal cyst, bilateral endometrioma measuring 3.7 and 4.5 centimeters, and ovarian tissue. In conclusion, this is a detailed protocol describing the steps required to perform a laparoscopic ovarian cystectomy for endometrioma using a fertility-sparing approach. Surgical management for endometriosis is favored for diagnosis, excision of disease, which reduces medically refractory pain, recurrence, and improves spontaneous pregnancy rates.Cystectomy may be helpful in patients pursuing assisted reproductive technologies. However, excision should only be performed if the patient is expected to have adequate ovarian reserve postoperatively. The surgeon must balance satisfactory removal of ovarian pathology to treat symptoms while limiting iatrogenic damage to normal ovarian parenchyma.Tubal patency is frequently assessed and management should be tailored to the patient's reproductive plans.

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