Endometriosis is a chronic gynecological condition in which endometrial-like tissue grows outside the uterus, most commonly affecting the ovaries, pelvic peritoneum, and uterosacral ligaments. Among its manifestations, ovarian endometriomas—commonly referred to as “chocolate cysts”—are one of the most frequent and clinically significant. They are characterized by cystic lesions filled with old, altered blood, resulting from cyclic bleeding of ectopic endometrial tissue within the ovary.

Endometriomas not only cause chronic pelvic pain and dysmenorrhea but also contribute significantly to infertility. Their management poses a challenge as treatment must balance the need for complete disease removal with preservation of ovarian reserve. In modern gynecology, laparoscopic surgery has become the gold standard for the diagnosis and management of endometriomas, offering minimally invasive, precise, and fertility-preserving treatment.

Pathophysiology and Clinical Presentation

Endometriomas develop when ectopic endometrial tissue infiltrates the ovarian cortex and progressively expands into cystic cavities filled with hemolyzed blood. Over time, the cyst walls become thickened and adherent to surrounding structures, leading to pelvic adhesions.

Clinical features include:

Chronic pelvic pain and dysmenorrhea.

Deep dyspareunia.

Infertility due to altered ovarian reserve and pelvic adhesions.

Palpable adnexal mass in some cases.

Ultrasound typically shows a unilocular cyst with homogenous “ground-glass” echogenicity, but MRI may be used for more complex cases.

Indications for Laparoscopic Surgery

Laparoscopy is indicated in the following situations:

Symptomatic endometriomas causing pain or infertility.

Ovarian cysts >4 cm in diameter.

Rapidly growing or atypical cysts requiring histological confirmation.

Recurrent endometriomas after medical therapy.

Cases where infertility treatment (e.g., IVF) is planned.

Laparoscopic Surgical Techniques

The choice of surgical technique depends on cyst size, patient age, fertility goals, and ovarian reserve.

Cystectomy (Preferred Method)

Involves complete excision of the cyst capsule from the ovarian cortex.

Achieved by identifying the cleavage plane between the cyst wall and ovarian tissue and stripping the cyst.

Provides the lowest recurrence rates and highest spontaneous pregnancy rates compared to other methods.

Care must be taken to avoid excessive cauterization that may damage ovarian follicles.

Ablative Techniques

Involves drainage of the cyst and destruction of the cyst wall by coagulation, vaporization (using laser or plasma energy), or bipolar electrosurgery.

Less invasive but associated with higher recurrence rates.

Sometimes considered in women with low ovarian reserve, where cystectomy may further compromise ovarian function.

Combined Technique

Partial cystectomy followed by ablation of the remaining cyst wall.

Offers a balance between reducing recurrence and preserving ovarian tissue.

Adhesiolysis

Endometriomas are often associated with dense pelvic adhesions involving ovaries, tubes, and pelvic peritoneum.

Careful adhesiolysis restores pelvic anatomy and enhances fertility.

Hemostasis

Achieved using fine bipolar coagulation or suturing to minimize thermal injury.

Hemostasis is critical to preserve ovarian reserve.

Intraoperative Considerations

Histopathology: All excised tissue should be sent for pathological evaluation to rule out malignancy.

Ovarian Reserve: Excessive damage to ovarian cortex must be avoided; the use of sutures instead of extensive coagulation is encouraged.

Concomitant Lesions: Excision of peritoneal endometriosis and deep infiltrating nodules is often performed during the same procedure.

Postoperative Care

Pain Management: NSAIDs and supportive care.

Hormonal Suppression: Postoperative use of combined oral contraceptives, progestins, or GnRH analogs may reduce recurrence rates.

Fertility Planning: Early referral to fertility specialists is advised if conception is delayed, as ovarian reserve may be reduced postoperatively.

Monitoring: Ultrasound follow-up at 6–12 months for recurrence.

Outcomes and Prognosis

Laparoscopic cystectomy remains the gold standard due to its superior long-term outcomes:

Pain Relief: Most patients experience significant improvement in pelvic pain and dysmenorrhea.

Fertility Outcomes: Spontaneous conception rates are higher after cystectomy than after drainage or ablation.

Recurrence Rates: Lowest with cystectomy (10–20%), higher with ablation or drainage alone (up to 50%).

Ovarian Reserve: There is a risk of diminished ovarian reserve, especially after bilateral cystectomy, but meticulous surgical technique can minimize damage.

Advantages of Laparoscopy

Minimally invasive with shorter recovery time.

Magnified visualization allowing precise excision.

Simultaneous management of other pelvic endometriotic lesions.

Reduced postoperative pain and better cosmetic results compared to laparotomy.

Conclusion

Laparoscopic management of endometriomas is the cornerstone of treatment in modern gynecology. Laparoscopic cystectomy, when carefully performed, offers the best outcomes in terms of pain relief, recurrence prevention, and fertility enhancement. Alternative approaches such as ablation or combined techniques may be considered in women with reduced ovarian reserve or specific fertility needs.

Ultimately, the success of laparoscopic management lies in a tailored approach that balances disease eradication with ovarian preservation, ensuring both symptom relief and reproductive potential. Multidisciplinary care, including postoperative medical therapy and fertility counseling, further optimizes long-term outcomes for women affected by endometriomas.