What is evisceration of an endometrioma in a female of reproductive age with a history of endometriosis?

What is Evisceration of Endometrioma

Evisceration of an endometrioma refers to a surgical technique where the cyst contents are drained and the internal cyst wall is stripped or ablated, but the cyst capsule is not completely excised—this is distinct from complete excisional cystectomy and is generally considered an inferior surgical approach.

Surgical Technique Definition

• Evisceration (also called "fenestration and coagulation" or "drainage and ablation") involves opening the endometrioma, evacuating its chocolate-colored contents, and destroying the internal cyst wall through coagulation or laser ablation without removing the entire cyst capsule 1

• This technique contrasts with laparoscopic excision of the endometrioma wall, which is considered the procedure of choice according to best available evidence, as it provides lower recurrence rates and improved fertility outcomes 1

Clinical Implications and Limitations

• Evisceration is associated with significantly higher recurrence rates compared to complete cyst wall excision, making it a less favorable option for definitive treatment 2, 1

• The technique does not provide adequate tissue specimens for histological examination, which is problematic since ruling out rare cases of unexpected ovarian malignancy is an important indication for surgical treatment 1

• Evisceration may be considered only in specific circumstances where preservation of maximal ovarian reserve is critical, such as in women with bilateral endometriomas, diminished ovarian reserve, or when the patient is immediately proceeding to IVF-ET 1, 3

Comparison with Standard Excisional Surgery

• Laparoscopic excision of the endometrioma capsule provides superior outcomes in terms of pain relief, pregnancy rates, and lower recurrence compared to evisceration techniques 1

• While concerns exist about surgical excision damaging ovarian reserve, recent evidence demonstrates that part of this damage may be due to the endometrioma itself rather than the surgical technique 1

• The choice between excision and evisceration should balance the risks of damaging ovarian reserve against the advantages of complete excision, particularly in women of reproductive age 1, 3

Common Clinical Pitfall

• The primary pitfall is choosing evisceration as a routine approach rather than reserving it for exceptional cases—this leads to higher recurrence rates and repeat surgeries, ultimately causing more cumulative damage to the ovary 2, 1