Endometriomas, also known as “chocolate cysts,” are a form of ovarian cyst resulting from endometriosis—a condition where endometrial tissue grows outside the uterine cavity. These cysts are filled with old, dark blood and commonly affect women of reproductive age, often causing chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. Surgical management of endometriomas is indicated when cysts are symptomatic, enlarging, or interfering with fertility. Among surgical approaches, laparoscopic ovarian cystectomy has emerged as the gold standard due to its minimally invasive nature, precision, and fertility-preserving potential.

Indications for Surgery

Laparoscopic cystectomy is recommended in women with:

Symptomatic endometriomas causing pelvic pain, dysmenorrhea, or dyspareunia.

Endometriomas larger than 4–5 cm, which are less likely to respond to medical therapy.

Infertility associated with ovarian endometriosis, particularly when other infertility factors are absent.

Cysts suspected of malignancy on imaging or tumor markers, although endometriomas are usually benign.

Preoperative evaluation involves a detailed history, pelvic examination, and imaging—typically transvaginal ultrasonography—to assess cyst size, morphology, and bilaterality. MRI may be used for complex or atypical lesions. Tumor markers like CA-125 can be assessed to rule out malignancy. Counseling regarding fertility preservation, surgical risks, and postoperative expectations is essential.

Surgical Technique

The procedure is performed under general anesthesia. The patient is positioned in lithotomy or supine position with a Trendelenburg tilt for optimal pelvic visualization. Pneumoperitoneum is established using carbon dioxide, and laparoscopic ports are inserted—usually a 10-mm umbilical port for the camera and two 5-mm accessory ports for instruments.

The pelvis is carefully inspected for the presence of endometriomas, adhesions, and associated endometriotic implants. Adhesiolysis is performed if necessary to mobilize the ovary and improve exposure. The ovarian cortex overlying the cyst is incised using laparoscopic scissors, harmonic scalpel, or cold knife technique. The endometrioma is then gently stripped from the ovarian stroma using a combination of traction and counter-traction. Meticulous dissection is essential to minimize loss of healthy ovarian tissue and preserve ovarian reserve.

Once the cyst is excised, the cavity is irrigated thoroughly to remove residual endometriotic fluid and debris. Hemostasis is achieved using bipolar cautery, sutures, or hemostatic agents. The cyst is retrieved in an endoscopic specimen bag to prevent spillage and contamination of the peritoneal cavity. Bilateral cysts are managed similarly if present. Adhesion prevention techniques, such as application of anti-adhesion barriers, are considered to improve postoperative outcomes.

Intraoperative Considerations

Laparoscopic cystectomy for endometriomas is technically demanding due to the cyst’s adherence to ovarian stroma and surrounding pelvic structures. Surgeons must carefully preserve ovarian tissue to maintain fertility potential. Complete excision of the cyst wall is important to reduce recurrence, which can be as high as 10–30% if residual tissue remains. Special care is needed to avoid injury to adjacent organs such as the bladder, bowel, ureters, and major vessels. Surgeons must be prepared to convert to laparotomy in cases of extensive adhesions, large cysts, or unexpected complications.

Postoperative Care and Recovery

Patients generally experience rapid recovery, with most discharged within 24–48 hours. Postoperative pain is mild and manageable with oral analgesics. Early ambulation is encouraged to reduce thromboembolic risk. Sexual activity and heavy physical exertion are usually restricted for 2–4 weeks. Follow-up includes ultrasonography to monitor ovarian healing, assess for recurrence, and evaluate ovarian reserve. Fertility counseling is advised, particularly in women seeking pregnancy, and assisted reproductive technologies may be discussed if conception is delayed.

Complications

While laparoscopic ovarian cystectomy is safe, potential complications include bleeding, infection, adhesion formation, cyst rupture, and inadvertent injury to surrounding structures. Recurrence of endometriomas is possible, especially if excision is incomplete or if extensive endometriotic implants remain. Preservation of ovarian tissue is critical to avoid diminished ovarian reserve and premature ovarian failure.

Advantages of Laparoscopy

Laparoscopic management of endometriomas offers multiple benefits compared to open surgery:

Minimally invasive: Smaller incisions, reduced postoperative pain, and faster recovery.

Fertility preservation: Careful dissection preserves healthy ovarian tissue.

Enhanced visualization: High-definition laparoscopes provide precise identification of cysts and adhesions.

Lower adhesion formation: Reduced trauma to surrounding tissues compared to laparotomy.

Cosmetic benefits: Small scars and quicker return to daily activities.

Conclusion

Laparoscopic ovarian cystectomy for endometriomas is a safe, effective, and fertility-preserving approach for women with symptomatic or large cysts. Careful preoperative assessment, meticulous surgical technique, and postoperative follow-up ensure optimal outcomes with minimal complications. This procedure not only relieves pain and improves quality of life but also enhances fertility potential, making it the gold standard for managing ovarian endometriomas in reproductive-age women.