Endometriomas, often called “chocolate cysts,” are ovarian cysts formed when endometrial tissue—the lining of the uterus—grows inside the ovary. These cysts are filled with thick, old blood and can range in size from a few millimeters to several centimeters. They are a common manifestation of endometriosis, a condition that affects millions of women worldwide and is closely linked with chronic pelvic pain and infertility.

Among the available treatment options, laparoscopic surgery has emerged as the gold standard for managing endometriomas, offering both diagnostic accuracy and therapeutic benefits.

Understanding Endometriomas

Endometriomas develop when endometrial tissue implants on the ovary and begins to bleed cyclically, just like the uterine lining during menstruation. Over time, repeated bleeding leads to cyst formation.

Symptoms

Pelvic pain, especially before and during menstruation.

Pain during sexual intercourse.

Painful urination or bowel movements during periods.

Infertility or difficulty conceiving.

While some women remain asymptomatic, many experience significant discomfort that interferes with quality of life.

Why Laparoscopic Surgery?

Medical management, such as hormonal therapy, may reduce symptoms but does not eliminate endometriomas. Surgery is often recommended when:

The cyst is larger than 4–5 cm.

The patient experiences severe pain.

There is suspicion of malignancy.

Infertility evaluation is ongoing, and cysts hinder ovarian function.

Laparoscopy is preferred because it:

Provides direct visualization of the cyst and surrounding pelvic structures.

Allows simultaneous diagnosis and treatment.

Offers a minimally invasive approach with smaller incisions, faster recovery, and less postoperative pain compared to open surgery.

Surgical Techniques in Laparoscopic Endometrioma Surgery

There are two primary approaches to managing endometriomas laparoscopically:

Cystectomy (Stripping Technique)

This is considered the gold standard procedure.

The surgeon makes a small incision in the cyst wall, carefully peeling it away from the ovarian tissue.

The cyst is completely removed, reducing the chance of recurrence.

The ovarian surface is then treated for hemostasis, usually with bipolar cautery or sutures.

Advantages:

Lower recurrence rates compared to other methods.

Improves spontaneous pregnancy rates in women with infertility.

Disadvantage:

Risk of reducing ovarian reserve if excessive ovarian tissue is inadvertently removed.

Ablation or Drainage

In this method, the cyst is drained, and the inner lining is destroyed using energy sources like laser or cautery.

While it reduces pain, recurrence rates are higher than cystectomy.

This approach may be considered in women with diminished ovarian reserve where preservation of ovarian tissue is critical.

Steps of the Laparoscopic Procedure

Anesthesia & Port Placement – The patient is placed under general anesthesia. Standard laparoscopic ports are inserted for visualization and instrument access.

Inspection of Pelvis – The surgeon examines the ovaries, uterus, fallopian tubes, and peritoneum to assess the extent of disease.

Cyst Identification & Mobilization – Adhesions are carefully released to expose the endometrioma.

Cyst Removal – Depending on the technique chosen, the cyst wall is stripped off (cystectomy) or destroyed (ablation).

Hemostasis & Reconstruction – Bleeding points are controlled while minimizing thermal injury to healthy ovarian tissue.

Specimen Retrieval – The cyst is placed in a retrieval bag and removed through one of the ports.

Final Assessment – The pelvic cavity is inspected for residual disease and washed with saline before closure.

Benefits of Laparoscopic Endometrioma Surgery

Pain Relief – Significant reduction in pelvic pain and dysmenorrhea.

Improved Fertility – Restores pelvic anatomy and enhances natural conception chances.

Lower Recurrence – Especially with cystectomy compared to drainage.

Faster Recovery – Patients resume normal activities earlier than with open surgery.

Cosmetic Advantage – Minimal scarring due to small incisions.

Risks and Complications

Although safe in expert hands, laparoscopic endometrioma surgery carries certain risks:

Ovarian tissue damage leading to decreased ovarian reserve.

Recurrence of cysts if removal is incomplete.

Adhesion formation post-surgery.

Rare complications such as bleeding, infection, or injury to nearby organs.

Preoperative assessment of ovarian reserve (AMH levels, antral follicle count) and careful surgical technique are crucial to minimizing risks.

Postoperative Care and Recovery

Most patients are discharged within 24–48 hours after surgery. Recovery tips include:

Adequate rest and gradual return to activity.

Pain management with prescribed medication.

Follow-up visits to monitor ovarian function and detect recurrence early.

Fertility counseling, especially for women desiring pregnancy, as chances improve within the first year after surgery.

Conclusion

Laparoscopic surgery for endometriomas remains the treatment of choice for women with symptomatic cysts, large lesions, or infertility concerns. Among surgical techniques, cystectomy offers the best long-term outcomes, though care must be taken to preserve ovarian reserve. With skilled surgical expertise, laparoscopy provides excellent results—relieving pain, restoring fertility potential, and improving the overall quality of life for women affected by endometriomas.