Gynecological conditions involving multiple pelvic pathologies can pose significant challenges to both diagnosis and treatment. Among these, peritoneal inclusion cysts combined with bilateral endometriomas represent a particularly complex clinical scenario. Both conditions cause pelvic pain, adnexal masses, and infertility, and their coexistence often complicates surgical decision-making.

Minimally invasive surgery has transformed the management of such cases. Laparoscopic surgery not only enables precise diagnosis but also provides an effective therapeutic approach, with advantages of less pain, faster recovery, and fertility preservation.

Understanding the Conditions
Peritoneal Inclusion Cyst

A peritoneal inclusion cyst (PIC) is a benign, fluid-filled lesion that forms when peritoneal fluid becomes trapped by adhesions. It most often occurs in premenopausal women with prior pelvic surgery, pelvic inflammatory disease, or endometriosis. The ovaries remain functional, but peritoneal adhesions prevent the normal absorption of peritoneal fluid, leading to cystic collections that mimic ovarian tumors.

Bilateral Endometrioma

Endometriomas, commonly known as “chocolate cysts”, are ovarian cysts filled with thick, old blood caused by endometriosis. When present bilaterally, they significantly impact fertility and quality of life. Symptoms include chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility.

The coexistence of PIC with bilateral endometriomas is uncommon but clinically important because it can:

Exacerbate pelvic pain

Mimic malignant ovarian tumors on imaging

Complicate surgical dissection due to adhesions

Role of Laparoscopic Surgery

Draining a peritoneal inclusion cyst alone is not sufficient, as recurrence is common. Similarly, bilateral endometriomas require meticulous cystectomy to preserve ovarian tissue. Laparoscopy provides the ideal platform to address both conditions simultaneously, with minimal morbidity.

Key benefits include:

Direct visualization of pelvic anatomy and pathology

Ability to distinguish PIC from true ovarian cysts

Precise adhesiolysis to restore pelvic anatomy

Preservation of ovarian function while excising endometriomas

Reduced adhesion formation compared to laparotomy

Surgical Technique

The surgical approach involves careful planning, stepwise dissection, and fertility-sparing techniques.

Preoperative Preparation

Imaging: Ultrasound and MRI help identify the cystic lesions, but laparoscopy provides definitive diagnosis.

Medical therapy: In selected cases, preoperative hormonal suppression (GnRH agonists) may reduce endometrioma size.

Counseling: Patients are counseled regarding recurrence risk, potential need for assisted reproduction, and fertility preservation options.

Anesthesia and Port Placement

General anesthesia is administered.

Standard laparoscopic ports are inserted: an umbilical port for the camera and 2–3 accessory ports for instrumentation.

Exploration and Diagnosis

The peritoneal cavity is inspected, revealing multiloculated fluid collections (PIC) and bilateral ovarian cysts consistent with endometriomas.

Adhesions are evaluated carefully to plan the surgical strategy.

Management of Peritoneal Inclusion Cyst

Adhesiolysis is performed meticulously to release trapped peritoneal fluid.

The cystic collection is drained, and surrounding adhesions are excised or lysed.

The ovary is preserved, as PIC does not originate from ovarian tissue.

Bilateral Endometrioma Surgery

Ovarian cystectomy is the gold standard.

A cortical incision is made, and the endometrioma wall is gently stripped from healthy ovarian tissue using traction–countertraction techniques.

Hemostasis is achieved with minimal cautery to preserve ovarian reserve.

Both ovaries are carefully reconstructed to restore anatomy.

Adhesion Prevention and Closure

Copious irrigation is done to clear residual endometriotic debris.

Anti-adhesion barriers may be placed in select cases.

Ports are closed, and specimens are retrieved for histopathology.

Postoperative Management

Pain control is usually minimal due to the minimally invasive approach.

Hormonal therapy (oral contraceptives, progestins, or GnRH analogs) may be prescribed to reduce recurrence risk.

Fertility counseling is essential, as bilateral endometriomas and adhesions can impair spontaneous conception. Many patients may benefit from assisted reproductive techniques (ART) after surgery.

Challenges and Considerations

Adhesions: Dense adhesions increase surgical complexity and risk of organ injury.

Ovarian Reserve: Bilateral cystectomy carries the risk of reduced ovarian reserve. Careful dissection is crucial.

Recurrence: Both PIC and endometriomas can recur; hence, postoperative medical therapy plays a supportive role.

Oncologic Safety: Although rare, malignancy must always be excluded with histopathology.

Conclusion

Laparoscopic surgery is the cornerstone of management for peritoneal inclusion cysts with bilateral endometriomas. It allows precise adhesiolysis, complete cyst excision, and fertility preservation through minimally invasive techniques. By combining advanced surgical skills with careful postoperative management, patients experience pain relief, improved pelvic anatomy, and enhanced chances of conception.

This approach exemplifies how laparoscopy has revolutionized gynecological surgery, transforming complex pelvic pathologies into treatable conditions with favorable outcomes.