Outside the uterine cavity. Among its varied presentations, paraovarian endometriomas are less common but clinically significant. These cystic lesions arise adjacent to the ovary within the broad ligament or mesosalpinx, and they can cause pelvic pain, dysmenorrhea, dyspareunia, infertility, and pressure symptoms on the urinary or gastrointestinal tract. Surgical management is often required when medical therapy fails, symptoms are severe, or fertility is compromised. Laparoscopic removal of paraovarian endometrioma, combined with the application of Interceed (an absorbable adhesion barrier), represents a modern approach to treating these lesions while minimizing postoperative adhesions and preserving reproductive potential.

Clinical Features of Paraovarian Endometrioma

Paraovarian endometriomas may remain asymptomatic for long periods, often being discovered incidentally during imaging or laparoscopy. When symptomatic, patients typically present with:

Chronic pelvic pain or lower abdominal discomfort

Painful menstruation (dysmenorrhea)

Dyspareunia (pain during intercourse)

Infertility or difficulty conceiving

Occasionally, urinary frequency or constipation if the cyst is large

Imaging modalities, particularly transvaginal ultrasonography and MRI, aid in differentiating paraovarian endometriomas from ovarian or tubal cysts and in planning the surgical approach.

Indications for Laparoscopic Removal

Laparoscopic surgery is indicated in the following scenarios:

Symptomatic endometriomas causing pain or pressure

Lesions associated with infertility

Large cysts (>3–4 cm) or rapidly enlarging masses

Failure of medical management with hormonal therapy

Need for fertility preservation, where ovarian tissue should be spared

Dr. R. K. Mishra emphasizes that minimally invasive management preserves ovarian reserve and minimizes adhesion formation, which is crucial for women desiring future fertility.

Preoperative Planning

Imaging Assessment: Transvaginal ultrasound or MRI is used to evaluate cyst size, location, and relation to the ovary, fallopian tube, and ureter.

Fertility Considerations: Hormonal therapy or preoperative counseling may be discussed.

Surgical Preparation: Standard preoperative evaluation, including anesthesia assessment and optimization of hemoglobin levels, is performed.

Surgical Technique

Patient Positioning and Anesthesia

The patient is placed supine under general anesthesia with Trendelenburg tilt for optimal pelvic exposure.

Port Placement

A 10 mm umbilical port is used for the laparoscope.

Two or three working ports (5 mm) are placed in the lower abdomen to allow instrument triangulation and safe access to the cyst.

Identification and Exposure

The paraovarian endometrioma is visualized, usually located lateral to the ovary within the broad ligament.

Surrounding structures, including the ureter, fallopian tube, and ovarian vessels, are identified and protected.

Cyst Enucleation

The cyst capsule is carefully dissected from the surrounding tissues using blunt and sharp dissection.

The cyst is separated from the ovary and fallopian tube while minimizing trauma to normal structures.

Complete excision is performed to reduce recurrence risk.

Hemostasis and Irrigation

Bipolar cautery or advanced energy devices are used to achieve hemostasis.

Copious irrigation of the pelvic cavity is performed to remove blood and debris.

Application of Interceed Adhesion Barrier

Interceed is an oxidized regenerated cellulose membrane applied to the surgical site after cyst removal and hemostasis.

It acts as a physical barrier between raw peritoneal surfaces, reducing the risk of postoperative adhesions, which are particularly important in preserving tubal function and fertility.

Specimen Retrieval and Closure

The cyst is removed via a laparoscopic retrieval bag or morcellation if needed.

Ports are removed under vision, and fascial closure is performed for ports larger than 10 mm. Skin incisions are closed with absorbable sutures.

Advantages of Laparoscopic Approach

Minimally invasive: Smaller incisions, less pain, and faster recovery

Enhanced visualization: Magnified views allow precise dissection and preservation of ovarian and tubal structures

Reduced adhesions: Application of Interceed minimizes postoperative scar formation and preserves fertility

Rapid recovery: Most patients are discharged within 24–48 hours

Cosmetic benefit: Minimal scarring compared to open surgery

Challenges and Limitations

Technical difficulty: Deep pelvic location and proximity to ureters and vessels require advanced laparoscopic skills

Risk of recurrence: Incomplete excision may lead to cyst recurrence

Adhesion formation: While reduced by Interceed, adhesions may still form in cases of extensive disease

Learning curve: Surgeons must be skilled in laparoscopic dissection and adhesion prevention techniques

Outcomes and Fertility Considerations

Studies indicate that laparoscopic excision of paraovarian endometriomas with adhesion barrier application significantly reduces adhesion formation, preserves ovarian and tubal function, and improves fertility outcomes. Symptom relief, including reduction in pelvic pain and dyspareunia, is excellent, with low recurrence rates when complete excision is achieved.

Conclusion

Laparoscopic removal of paraovarian endometrioma with Interceed application is a safe and effective technique that addresses both the pathological lesion and the long-term risk of adhesions. By combining meticulous laparoscopic excision with adhesion prevention strategies, surgeons can provide optimal symptom relief, preserve reproductive potential, and facilitate rapid recovery. This approach exemplifies modern gynecologic surgery, prioritizing minimally invasive techniques, patient safety, and improved quality of life.