An endometrial cyst, commonly known as an endometrioma, is a type of ovarian cyst caused by endometriosis, a condition in which endometrial-like tissue grows outside the uterus. These cysts are typically filled with dark, old blood, giving them the characteristic name “chocolate cysts.” Endometrial cysts can cause pelvic pain, menstrual irregularities, infertility, and, in some cases, complications like rupture or ovarian damage. With advances in minimally invasive techniques, laparoscopic surgery has become the gold standard for managing endometrial cysts, offering both diagnosis and treatment with minimal morbidity.

Understanding Endometrial Cysts

Endometrial cysts develop when endometrial tissue implants on the ovaries. Each menstrual cycle, these implants respond to hormonal changes, leading to bleeding and accumulation of blood inside the ovary. Over time, the trapped blood becomes thick and dark, forming a cyst. These cysts may range from a few millimeters to several centimeters in size and often occur bilaterally.

Women with endometriomas frequently present with:

Chronic pelvic pain

Severe dysmenorrhea (painful menstruation)

Dyspareunia (pain during intercourse)

Infertility due to damage to ovarian tissue or distortion of pelvic anatomy

Indications for Surgery

Not all endometrial cysts require surgical intervention. Dr. R. K. Mishra and other laparoscopic experts recommend surgery in the following scenarios:

Cyst size greater than 4–5 cm

Severe pelvic pain unresponsive to medical therapy

Infertility in women planning assisted reproductive techniques

Suspicion of malignancy (though rare, endometriomas can coexist with ovarian cancer)

Rapid growth or rupture of the cyst

For smaller cysts and minimal symptoms, medical management with hormonal therapy may be considered. However, surgery remains the definitive treatment in many cases.

Role of Laparoscopy

Laparoscopy plays a dual role in the management of endometrial cysts:

Diagnosis – Direct visualization of pelvic structures allows confirmation of endometriosis and exclusion of other pelvic pathologies. Chromopertubation can also be performed during laparoscopy to assess tubal patency in women with infertility.

Treatment – Laparoscopic surgery enables precise removal of endometrial cysts with minimal trauma to surrounding ovarian tissue, thereby preserving fertility.

Surgical Techniques

Several laparoscopic methods are employed in managing endometrial cysts:

Cystectomy (Preferred Method)

The cyst wall is carefully dissected and peeled away from the ovarian cortex.

This technique offers the lowest recurrence rates and improves spontaneous pregnancy rates.

Care is taken to minimize damage to healthy ovarian tissue to preserve ovarian reserve.

Drainage and Coagulation

The cyst is opened, drained, and the inner lining is coagulated using bipolar energy or laser.

While this method is simpler, it carries higher recurrence rates compared to cystectomy.

Combined Techniques

Sometimes, partial cystectomy followed by coagulation of residual tissue is used to balance cyst removal with preservation of ovarian function.

Adhesiolysis

Endometriomas are often associated with pelvic adhesions that distort the ovaries, tubes, and uterus. Laparoscopy allows careful adhesiolysis, restoring pelvic anatomy.

Steps of Laparoscopic Cystectomy

Dr. R. K. Mishra emphasizes a meticulous stepwise approach in his lectures:

Creation of pneumoperitoneum with a Veress needle or open technique.

Insertion of trocars and introduction of a laparoscope for visualization.

Identification of the cyst and assessment of pelvic adhesions.

Incision of the cyst wall and careful traction-countertraction technique to separate the cyst capsule from ovarian tissue.

Coagulation of bleeding points with bipolar cautery, avoiding excessive thermal damage.

Reconstruction of the ovary if necessary, to maintain its normal shape.

Copious irrigation to reduce residual endometriotic tissue and minimize adhesion formation.

Advantages of Laparoscopic Management

Minimally invasive with smaller incisions and faster recovery

Shorter hospital stay compared to open surgery

Improved visualization of pelvic structures with magnification

Precise dissection, preserving ovarian tissue and function

Lower recurrence rates when complete cystectomy is performed

Fertility preservation, especially critical in young women

Risks and Limitations

As with any surgical procedure, laparoscopic management has potential risks:

Injury to ovarian reserve due to excessive removal of healthy tissue

Adhesion formation, which can impact fertility

Recurrence of endometriosis, even after complete cystectomy

Rare complications such as bleeding, infection, or damage to surrounding organs

Proper surgical technique and postoperative care are essential to reduce these risks.

Postoperative Care and Fertility Considerations

Post-surgery, patients may be prescribed hormonal therapy to suppress recurrence of endometriosis. For women seeking pregnancy, fertility may improve naturally after cystectomy, or assisted reproductive techniques like IVF may be recommended, especially if other infertility factors are present.

Conclusion

Laparoscopic surgery for endometrial cysts offers a safe, effective, and fertility-preserving option for women suffering from endometriomas. By combining diagnostic accuracy with minimally invasive treatment, laparoscopy not only relieves pain but also restores pelvic anatomy and improves fertility outcomes. As Dr. R. K. Mishra emphasizes in his teachings, success lies in meticulous surgical technique, careful handling of ovarian tissue, and holistic management of endometriosis. For women with endometrial cysts, laparoscopic surgery represents hope for improved quality of life and the possibility of motherhood.