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.
