Endometriosis is a complex gynecological condition in which endometrial-like tissue grows outside the uterus, often affecting the ovaries, fallopian tubes, and pelvic lining. One of the most challenging forms of this disease is the development of ovarian endometriomas, also called “chocolate cysts,” due to the thick, old blood they contain. While smaller endometriomas can sometimes be managed conservatively, larger ones—typically over 4–5 cm—often require surgical intervention. Laparoscopic surgery for large endometrioma has become the preferred approach worldwide because it is minimally invasive, offers faster recovery, and provides better fertility outcomes compared to open surgery.

Understanding Large Endometriomas

An endometrioma forms when endometrial tissue invades the ovary and creates a cyst. Over time, it fills with dark, degraded blood, giving it a characteristic appearance on ultrasound and at surgery. Large endometriomas can cause:

Chronic pelvic pain

Painful periods (dysmenorrhea)

Pain during intercourse (dyspareunia)

Infertility

Risk of ovarian reserve reduction

Ovarian torsion or rupture in rare cases

When the cyst is large, the ovary can become distorted, making ovulation less efficient. Furthermore, large endometriomas may obscure underlying malignancy, so surgical evaluation is often necessary.

Why Laparoscopy is Preferred

In the past, laparotomy (open surgery) was often used for large ovarian cysts, but advancements in laparoscopic techniques now allow surgeons to manage even very large endometriomas effectively. Laparoscopy is considered the gold standard because it offers:

Magnified visualization of pelvic anatomy

Precise dissection with minimal trauma

Reduced postoperative pain

Faster recovery and shorter hospital stay

Better cosmetic outcomes with small scars

Enhanced fertility preservation when done carefully

Surgical Techniques in Laparoscopic Management

The primary goals of laparoscopic surgery for large endometriomas are to remove the cyst, relieve symptoms, and preserve as much healthy ovarian tissue as possible. The main approaches include:

Cystectomy (Stripping Technique)

This is the most widely accepted method. The surgeon carefully opens the cyst, identifies the cleavage plane, and strips the cyst wall from the ovarian cortex. Cystectomy reduces recurrence rates compared to drainage alone and provides better fertility outcomes. However, care must be taken to avoid excessive cauterization, which can damage ovarian reserve.

Drainage and Coagulation

In some cases, the cyst is drained and its inner lining ablated using bipolar energy or laser. While this is technically easier, the recurrence rate is higher compared to cystectomy. This method may be reserved for patients with very low ovarian reserve or when cystectomy poses excessive risk.

Combined Approach

Some surgeons combine drainage with partial cyst wall excision and coagulation of the remaining tissue. This method balances recurrence prevention with ovarian tissue preservation.

Fertility-Sparing Principles

For women desiring pregnancy, every effort is made to preserve ovarian tissue. Advanced energy devices, minimal cauterization, and gentle tissue handling are used to maximize postoperative ovarian reserve.

Challenges in Large Endometrioma Surgery

Operating on large endometriomas can be technically demanding. The challenges include:

Distorted anatomy due to adhesions from chronic inflammation.

Risk of ovarian tissue loss, as the cyst wall is closely attached to ovarian cortex.

Risk of recurrence, particularly in younger women and those with severe endometriosis.

Impact on fertility, since aggressive surgery may reduce ovarian reserve.

Bleeding risks, requiring careful hemostasis without overusing energy sources.

An experienced laparoscopic surgeon is crucial for achieving optimal outcomes.

Recovery and Postoperative Care

Recovery after laparoscopic endometrioma surgery is typically faster than open procedures. Most patients are discharged within 24–48 hours. Key aspects of recovery include:

Early mobilization to prevent complications

Pain management with minimal opioid use

Resumption of normal activities within 1–2 weeks

Follow-up to monitor ovarian function and recurrence

In many cases, medical therapy such as hormonal suppression (e.g., oral contraceptives, GnRH analogues, or progestins) may be prescribed postoperatively to reduce recurrence risk.

Impact on Fertility

One of the main concerns in treating large endometriomas is fertility. Surgery can improve pain and increase spontaneous conception rates by restoring ovarian anatomy and function. However, removal of cysts may also reduce ovarian reserve. Therefore, a careful balance is needed. For women planning assisted reproduction, some guidelines suggest proceeding directly to IVF in certain cases rather than repeated surgery.

Conclusion

Laparoscopic surgery for large endometrioma represents a significant advancement in gynecological surgery, offering women an effective, minimally invasive solution for pain relief, improved fertility, and quality of life. While surgery is not without challenges, especially in terms of preserving ovarian reserve, skilled laparoscopic techniques allow safe removal of even large cysts with excellent outcomes.

Each case must be individualized, considering the woman’s symptoms, age, fertility goals, and overall health. With careful patient selection and expert surgical execution, laparoscopic surgery continues to stand as the gold standard in the management of large endometriomas.