What are the operative steps in cystectomy for endometriotic cysts?

Operative Steps in Cystectomy for Endometriotic Cysts

Laparoscopic ovarian cystectomy using the stripping technique is the treatment of choice for endometriomas, following a systematic 10-step approach that maximizes ovarian preservation while minimizing recurrence. 1, 2

Preoperative Evaluation and Patient Selection

• Surgical indications include: symptomatic cysts, cysts >4 cm (due to rupture/torsion risk), infertility after 1-1.5 years of failed conception attempts, or when in vitro fertilization is not an option 3
• Avoid surgery for: small asymptomatic cysts, especially in patients >35 years, as surgical treatment can compromise ovarian reserve 3
• Preoperative imaging should identify the size, location, and extent of disease including associated pelvic endometriosis 1, 2

Systematic 10-Step Surgical Technique

Step 1: Trocar Placement and Initial Inspection

• Insert Verres needle at umbilicus for CO2 insufflation, followed by 10-mm umbilical trocar for laparoscope 1, 4
• Place three 5-mm accessory trocars (one right-sided, two left-sided) for instrument access 1, 4
• Perform standard inspection of the entire pelvic cavity, identifying all endometriotic lesions and adhesions 1, 2

Step 2: Adhesiolysis and Ovarian Mobilization

• Release adhesions between the ovary and surrounding structures (bowel, pelvic sidewall, broad ligament) using sharp dissection 1, 2
• Mobilize the ovary completely to allow 360-degree visualization and access 2
• Identify and preserve the ovarian blood supply during mobilization 1

Step 3: Cyst Drainage and Exposure

• Puncture the cyst directly with a trocar to drain contents and prevent spillage into the peritoneal cavity 1, 2
• Aspirate chocolate-colored fluid completely 1
• Irrigate the cyst cavity with saline to clean residual contents 1, 2
• Perform a cold cut (without electrocautery) at the puncture site to better identify the cyst capsule 1

Step 4: Identification of the Cleavage Plane

• Locate the natural plane between the endometrioma capsule and normal ovarian cortex 1, 2
• This is the critical step that determines success of the stripping technique 2
• The capsule appears as a white, fibrous layer distinct from the yellow ovarian tissue 1

Step 5: Easy Dissection Phase

• Use gentle traction on the cyst capsule with one grasper while applying countertraction on the ovarian cortex with another 1, 2
• Peel the capsule away from the ovarian cortex in a systematic fashion, working circumferentially 1, 2
• Preserve as much ovarian tissue as possible by staying in the correct plane 1
• Avoid using electrocautery during dissection to minimize thermal damage to ovarian reserve 1

Step 6: Difficult Dissection Phase

• In areas where the capsule is densely adherent, use sharp dissection with scissors rather than blunt stripping 2
• Take extra care near the ovarian hilum where blood vessels enter 2
• If the plane is lost, re-establish it by finding an area where dissection is easier 2

Step 7: Complete Capsule Removal

• Ensure complete excision of the entire cyst capsule to minimize recurrence risk 1, 3
• Inspect the ovarian fossa for any remaining endometriotic tissue 2
• Remove any visible endometriotic implants from the ovarian fossa 2

Step 8: Hemostasis

• Achieve hemostasis using bipolar electrocautery with minimal and precise application to avoid excessive ovarian damage 1, 2
• Use the lowest effective energy setting 1
• Apply pressure with gauze for minor bleeding points before resorting to cautery 2

Step 9: Ovarian Reconstruction

• Reapproximate the ovarian edges using simple interrupted sutures (typically 3-0 or 4-0 absorbable suture) 1
• Re-establish normal ovarian anatomy 1, 2
• Ensure the ovary is positioned in its anatomic location without tension 1

Step 10: Treatment of Associated Disease and Completion

• Excise all concomitant pelvic endometriosis including peritoneal implants, uterosacral ligament nodules, and adhesions to prevent leaving disease behind 1, 2
• Perform copious irrigation of the pelvis 2, 4
• Place the cyst in an extraction bag, morcellate if necessary, and remove through the umbilical port 2, 4
• Remove trocars under direct visualization and close fascial defects ≥10 mm 2

Special Considerations for Bladder Endometriosis

• When bladder involvement is present, use a combined cystoscopic and laparoscopic approach 4
• Place ureteral stents bilaterally before excision to avoid ureteral injury 4
• Demarcate the bladder nodule margins via cystoscopy using needle electrode before laparoscopic excision 4
• Perform partial cystectomy laparoscopically after cystoscopic demarcation, ensuring margins are ≥2 cm from ureteral orifices 4
• Close the bladder defect in one layer with 3-0 absorbable suture after placing stay sutures 4
• Perform completion cystoscopy to verify suture integrity 4

Critical Pitfalls to Avoid

• Never use morcellation for endometriomas as spillage increases recurrence risk 1
• Avoid excessive electrocautery during hemostasis as this destroys healthy ovarian tissue and compromises fertility 1, 2
• Do not leave residual cyst capsule behind, as incomplete excision significantly increases recurrence rates 3, 5
• Avoid transurethral resection alone for bladder endometriosis, as complete excision is virtually unachievable and perforation risk is high 4
• Do not perform bilateral oophorectomy in women desiring future fertility; unilateral oophorectomy with contralateral ovarian preservation is the most effective prevention for recurrence when childbearing is complete 3

Postoperative Management

• Consider postoperative hormonal suppression (GnRH analogues for 3-6 months, continuous oral contraceptives, or progestin-releasing IUD) to reduce recurrence risk 3, 4
• For bladder endometriosis cases, maintain catheter drainage for 10 days with cystogram before removal 4
• Advise patients with infertility to attempt conception as soon as possible; consider IVF for women >35 years or those who fail to conceive 3