What is the recommended surgical approach for a patient with an endometrioma?

Laparoscopic Ovarian Cystectomy is the Preferred Surgical Approach for Endometriomas

Laparoscopic ovarian cystectomy (complete excision of the cyst wall) is the recommended surgical technique for endometrioma management, offering superior outcomes compared to drainage, ablation, or sclerotherapy. 1, 2

Primary Surgical Approach

Minimally Invasive Technique is Standard

• Laparoscopy is the preferred first-line surgical modality for diagnosis and treatment of endometriomas, providing shorter hospital stays, less postoperative pain, faster recovery, and improved quality of life compared to laparotomy. 1, 2
• The American College of Surgeons specifically endorses laparoscopic ovarian cystectomy as the technique of choice due to its ability to enable definitive pathologic diagnosis, provide superior symptom improvement, reduce recurrence rates, and optimize future fertility outcomes. 1

Cystectomy Versus Alternative Techniques

• Complete excision of the endometrioma cyst wall (cystectomy) is superior to cyst drainage, ablation, or sclerotherapy for multiple reasons: 1, 2, 3
  • Enables pathologic diagnosis to rule out rare cases of ovarian malignancy 3
  • Provides better symptom relief 1, 2
  • Reduces recurrence rates 1, 2
  • Optimizes fertility outcomes 1, 2

Technical Considerations Based on Endometrioma Characteristics

Small, Densely Fibrotic Endometriomas

• Small (1-3 cm) densely adherent endometriomas present unique surgical challenges due to dense fibrosis of the cyst capsule that obliterates the plane with normal ovarian cortex. 2
• Circular excision of ovarian tissue around the initial adhesion site followed by stripping may provide better hemostasis and reduce operative time compared to direct stripping alone. 4

Large Endometriomas

• Large endometriomas (>3 cm, up to 20 cm or greater) carry unique challenges due to adhesions between the cyst and pelvic structures. 2, 4
• These require surgical treatment and cannot be managed expectantly. 4

Robotic-Assisted Laparoscopy as an Enhancement

• Robotic-assisted laparoscopy can be considered as an enhancement to standard laparoscopy, particularly in obese patients or those with complex anatomy. 5, 6
• Robotic approaches perform similarly to conventional laparoscopy with comparable or improved perioperative outcomes. 6

Adjunctive Medical Management

Perioperative Hormonal Suppression

• Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. 2
• However, medical treatment alone is ineffective for endometriomas and should not replace surgery when surgical intervention is indicated. 3, 7

Critical Pitfalls to Avoid

Ovarian Reserve Concerns

• While concerns exist about surgical excision damaging ovarian reserve, recent evidence demonstrates that part of the damage may be due to the presence of the endometrioma itself rather than the surgery. 3
• The benefits of surgery (pain relief, pregnancy rates, pathologic diagnosis) must be balanced against potential ovarian reserve impact. 3

Inadequate Surgical Technique

• Avoid simple drainage or ablation techniques, as these result in higher recurrence rates and do not provide tissue for pathologic diagnosis. 1, 2
• Complete removal of the cystic wall should be achieved in >90% of cases to minimize recurrence. 4

Inappropriate Use of Laparotomy

• Laparotomy should be reserved only for cases where laparoscopy is technically not feasible due to extensive adhesions or other anatomic constraints. 1
• The vast majority of endometriomas can and should be managed laparoscopically. 2, 3

Special Considerations for Fertility

• For infertile women with endometriomas, laparoscopic excision prior to IVF does not offer additional benefit over expectant management in asymptomatic cases. 7
• However, for symptomatic women or those not pursuing IVF, surgical excision remains the preferred approach with pregnancy rates of approximately 60% following laparoscopic cystectomy alone. 8