Review Article
Surgical Tips for the Conservative Surgical Treatment of Ovarian Endometrioma: An Overview with Video Presentation
Seok Ju Seong and Mi-La Kim*
Department of Obstetrics & Gynecology, CHA Gangnam Medical Center, CHA University, Republic of Korea
*Corresponding author: Mi-La Kim, Department of Obstetrics & Gynecology, CHA Gangnam Medical Center, CHA University, 566, Nonhyeon-ro, Gangnam-gu, Seoul 06135, Republic of Korea
Published: 05 Oct, 2018
Cite this article as: Seong SJ, Kim M-L. Surgical Tips for
the Conservative Surgical Treatment of
Ovarian Endometrioma: An Overview
with Video Presentation. Clin Surg.
2018; 3: 2142.
Abstract
Surgical treatment is the most effective treatment modality for women with endometriosis-related
pain or infertility. However, surgical treatment can reduce the ovarian reserve owing to considerable
adherence between the ovarian endometrioma and underlying ovarian parenchyma. In this review,
we focus on surgical tips for the conservative surgical treatment of ovarian endometrioma to reduce
ovarian damage, with and accompanying video presentation.
Keywords: Ovarian endometrioma; Surgical treatment; Ovarian reserve
Introduction
The reported incidence of endometriosis for women of childbearing age ranges from 0.8% to
2%, and the incidence rate is 2-5 times higher in infertile women. About one-third of all women
with endometriosis are infertile [1-6]. Endometrioma is defined as endometriosis cysts that form as
a result of the accumulation of endometrial tissue within the ovary. It accounts for 35% of benign
ovarian cysts and is found in 20% to 40% of patients with endometriosis [7-9]. Endometriomas
contain sticky chocolate-colored fluid that originates from previous bleeding within the ovary (Figure
1). They often adhere to the peritoneum of the pelvis, causing the ovary to invaginate, and rarely
develop into malignant tumors. While medical treatment can reduce the size of endometriomas by
up to 57%, surgical treatment is considered the most effective treatment modality [10].
Surgical treatment is indicated for patients who have dysmenorrhea, pelvic pain, dyspareunia,
or are currently undergoing treatment for infertility, for whom an increase in the likelihood of
pregnancy after surgery seems promising, as well as for those who are suspected of having rupture
or torsion of ovarian tumors. Compared to laparotomy, laparoscopy has the advantages of faster
recovery, reduced use of analgesics, a shorter hospital stay, and lower rates of postoperative adhesion
compared to laparotomy, with similar pregnancy and relapse rates [11].
While laparoscopy is generally accepted as the standard method of conservative treatment
for ovarian endometriomas, the detailed steps involved in the procedure are still controversial.
Excessive resection of endometriomas can lead to substantial destruction of normal ovarian tissues,
while incomplete surgery can lead to early relapse. Although an increase in natural pregnancy rates
can be expected with laparoscopy for infertile patients, the risk of damaging the ovary owing to the
surgical procedure must be considered.
Therefore, the present review discusses different types of laparoscopy techniques for the
conservative treatment of endometriomas, their advantages and disadvantages, and describes each
procedure in detail.
Surgical Treatment of Endometrioma
Most common conservative treatment of endometrioma is removal or resection of the
endometrioma. Sclerotherapy and ablation are also considered as conservative treatment.
Drainage and sclerotherapy
Endometriomas are drained under ultrasonic guidance, and rinsed with ethanol, tetracycline,
or methotrexate to induce their sclerosis. While this procedure has been reported to produce
satisfactory results, it is not recommended since it results in little symptom relief and is associated
with high risk of infection, high relapse rates, and risk for peritoneal metastases in the case of patients
with malignant ovarian tumors [12,13]. However, the procedure may
be useful during the collection of oocytes in patients with reduced
ovarian reserve or for those who cannot undergo surgical treatment.
Drainage and ablation
After making an incision on an endometrioma, its inner wall is
cauterized or coagulated with a laser and vaporized with a carbondioxide
laser. This procedure prevents damage to normal ovarian
tissue and relieves pelvic pain. However, in a systematic review that
compared ablation to laparoscopy, ablation was associated with
lower pregnancy rates and less pain reduction, and had relatively
high reoperation and relapse rates [14]. In addition, while ablation
is effective for small lesions, it requires a substantial amount of time
for large cysts, can cause heat damage to the surrounding tissues
and normal ovarian tissues, and does not destroy all cystic walls.
Therefore, ablation is currently performed only for sites where
removal of ovarian cysts is incomplete.
Cystectomy
Cystectomy is the most preferred method of surgery over the
procedures mentioned above. It is associated with low rates of
recurrent endometriomas or symptoms, and higher pregnancy rates
[15-17]. Disadvantages of the procedure include ovarian adhesions
and reduced ovarian reserve.
Cystectomy involves isolation of the endometrioma from the
surrounding adhesions, complete aspiration of cystic contents,
and dissection of normal ovarian tissues from the cystic wall using
fine tools, followed by stripping of the cystic wall from the normal
ovary. It is important to accurately identify the boundary between
the normal ovary and the cystic wall before stripping. Boundaries
between endometriomas and the normal ovary are often not clearly
visible. Careless removal of endometriomas or inadvertent removal
of the normal ovarian cortex can lead to loss of follicles and a
reduced ovarian reserve. Loss of ovarian reserve can also result from
electrocauterization used to stop bleeding after the removal of cystic
walls. It is important to accurately identify the boundary between an
endometrioma and the normal ovary and minimize the coagulation
process by preventing bleeding in order to reduce these risks. Details
of the steps involved in laparoscopy are provided below.
First, adhesions around the endometrioma are removed to enable
mobilization.
Since endometriomas are accompanied by pelvic endometriosis,
they often adhere to other organs. Even if the adhesion is not severe,
endometriomas are often found adherent to the peritoneum of the
pelvis. Endometriomas must be free of adhesions before surgery.
Second, an incision is made on the endometrioma. An incision must
be made on the antimesenteric surface as far away from the hilum of
the ovary as possible (Figure 2). Cyst rupture commonly occurs during
the removal of adhesions. An incision is made by using scissors or a
laser while holding the ruptured area or the normal ovarian cortex
with forceps. Ideally, an incision should be made along the longest
diameter of the endometrioma. Such an incision not only makes the
surgical procedure much easier, but also provides sufficient visibility
during the coagulation process.
Third, once an incision is made, the boundary between the
ovarian cortex and the cystic wall is identified, and the cystic wall is
removed.
Accurate boundary identification reduces damage to the
normal ovarian tissue. If the endometrioma has not ruptured, it is
recommended to rupture the endometrioma after detaching the
ovary from the cystic wall to a certain extent for easier identification
of the boundary. If rupture has already occurred, it is recommended
to perform detachment where the boundary is more visible through
an incision. In case of incomplete removal of endometrioma owing
to inaccurate identification of the border, it may be useful to perform
cauterization on the cystic wall. Until these procedures, Supplemental
Digital Content 1 was presented.
And finally, coagulation is performed.
Table 1
Coagulation Techniques after Ovarian Cystectomy
Coagulation techniques include bipolar coagulation, laser
ablation, suturing, hemostatic sealant, and vasopressin injection
(Table 1). This step is important for conservation of the ovarian
reserve.
Bipolar coagulation technique
Bipolar coagulation is easy to perform and requires a short amount
of time, but can produce local inflammation during the coagulation
process, and damage normal follicles. Extensive coagulation around
the hilum can result in an especially significant loss of follicles due to
reduced blood flow into the ovary. Bipolar coagulation is associated
with higher rates of reduced ovarian reserve compared to other
coagulation techniques.
Laser ablation
Laser ablation involves shallow tissue vaporization of the
glandular epithelium and subjacent stroma. While laser ablation
has the advantage of limited smoke production, which ensures good
vision, and little damage to the ovarian tissue, it has weak coagulation
effects, which makes it difficult to accurately assess the layer thickness
[18]. Donnez et al. performed partial cystectomy by stripping for
80% to 90% of endometriomas and proposed a method in which
the remaining 10% to 20% of the endometriomas around the hilus,
which contains substantial functional ovarian tissue and has a poorly
visible cleavage plane, were vaporized with a CO2 laser. They reported
similar volumes and antral follicle counts between the treated ovary
and the opposite ovary [19].
Sutures
Sutures can reduce damage to the normal ovarian tissue by
minimizing the coagulation process while reapproximating the
ovarian tissue. However, suture techniques are difficult to learn,
require a long time if performed by inexperienced surgeons, and
can damage normal ovarian tissue. Suture techniques are reported
to have a smaller impact on reduced ovarian reserve [20] and similar
relapse and pregnancy rates compared to bipolar coagulation [21].
Hemostatic sealants
The hemostatic sealants with the trade name FloSeal© was
approved by the Food and Drug Administration in 1999. Its
constituents include thrombin, calcium chloride, and specifically
treated or purified gelatin, and it consists of two separate syringes.
Once the site of bleeding is identified, a sufficient quantity of FloSeal
Matrix is applied by using the tip of a syringe until a small “hill” forms
(Figure 3). Two minutes after fixing the Floseal Matrix onto the lesion
by bringing it into contact with the bleeding site with wet gauze, the
gauze is lifted to inspect the lesion. To prevent the blood clot from
collapsing, the gauze is removed after the bleeding is stopped. If the
gauze becomes stuck to the newly formed blood clot, the clot is rinsed
with a saline solution that has not been treated with heparin, and
the sponge is carefully removed from the treated site. Once bleeding
stops, any substances that did not mix into the blood clot are lightly
washed off. The FloSeal© that has fused with the blood clot is not
physically separated, and any substances that have mixed with the
blood clot are left as they are. The advantages of this procedure are
that it is easy to perform and causes little tissue damage [22,23]. A
recent systematic review and meta-analysis comparing hemostatic
sealants with sutures and bipolar coagulation reported that hemostatic
sealants had a smaller influence on ovarian reserve in terms of anti-
Müllerian hormone (AMH) [24]. However, hemostatic sealant is
expensive and has been reported to cause thrombosis or small bowel
obstruction after use. They are also believed to be associated with risk
for viral transmission, although no study to date has reported on this
association [25-27].
Vasopressin
The final coagulation technique to discuss is the use of vasopressin.
This technique involves injection of a diluted vasopressin solution
into 3-4 points on the boundary between the ovarian parenchyma
and the cystic wall while avoiding large vessels before separating the
cystic wall from the ovary (Figure 4). This method not only enables
more accurate separation of the cystic wall through hydrodissection,
but also reduces bleeding through the effects of vasopressin. Since
the cystic wall is separated precisely, the operation time is reduced,
and the removal of normal ovarian tissue can be prevented.
Furthermore, reduced bleeding minimizes unnecessary steps in the
coagulation process, thereby reducing damage to ovarian tissue [28-
30]. However, Ghafarnejad et al. compared vasopressin and saline
injection in a randomized prospective study and found no statistical
differences in operation time, frequency of electrocoagulation, or
postoperative antral follicle count change [29]. Qiong-Zhen et al.
performed prospective randomized study comparing the number
of coagulation events, thickness of ovarian tissue removed, and
basal follicle-stimulating hormone (FSH) levels in patients with
bilateral ovarian endometriomas treated with stripping only, saline
injection, or vasopressin injection. Campared to stripping only, the
saline-treated group demonstrated a lower frequency of coagulation,
less removal of ovarian tissue, and lower preoperative FSH levels,
while the vasopressin group had fewer coagulation events and lower
preoperative FSH levels than the saline group. However, research on
AMH, which reflects the capacity of the ovary to store eggs, is still
lacking; therefore, additional randomized controlled trials must be
conducted. To date, there has been no report of delayed bleeding after
surgery, which is a side effect of vasopressin use.
Figure 1
Figure 1
An overview of ovarian endometrioma which contains sticky
chocolate-colored fluid that originates from previous bleeding within the
ovary.
Figure 2
Figure 2
An incision is made on the surface of endometrioma. Usually
longitudinal incision on the antimesenteric surface is preferred for the
prevention of damage on the hilum area.
Figure 3
Figure 3
A hemostatic sealant is applied. On the bleeding site, a sufficient
quantity of hemostatic sealant is applied by using the tip of a syringe until a
small “hill” forms.
Figure 4
Figure 4
Vasopressin injection: 3-4 points on the boundary between the
ovarian parenchyma and the cystic wall while avoiding large vessels before
separating the cystic wall from the ovary.
Conclusion
Currently, there is no definitive treatment for the optimal management of endometriomas. Pharmacotherapy results in temporary pain relief and prevents relapses, whereas ultrasoundguided drainage has limited effects. While the general consensus is that laparoscopic cystectomy is the most effective conservative treatment for endometriomas, its effects on reducing ovarian reserve remain controversial. The most important steps of this procedure are, first, the separation of the cystic wall from the normal ovarian tissue by accurately identifying the boundary between them; second, removing as much of the cystic wall as possible; and, third, the coagulation. To minimize damage to the ovarian tissue during the coagulation process, it is important to employ various techniques, as described above, according to the situation rather than using a single technique.
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