Can two different gynecological conditions be managed through a combined minimally invasive surgical approach? This educational surgical video from World Laparoscopy Hospital demonstrates the management of bilateral ovarian endometriomas along with a submucous uterine fibroid under the expertise of Prof. Dr. R. K. Mishra.

The procedure brings together advanced laparoscopic ovarian surgery and hysteroscopic fibroid removal. It highlights the importance of accurate diagnosis, appropriate surgical planning, pelvic anatomical knowledge, meticulous adhesiolysis, preservation of healthy ovarian tissue, and precise treatment of pathology within the uterine cavity.

For gynecologists and laparoscopic surgeons, this case provides an opportunity to understand how multiple gynecological conditions can be evaluated and addressed during one planned operative episode when clinically appropriate.

Two Conditions Requiring Different Surgical Techniques

Bilateral Endometriomas: Managing Ovarian Disease

Endometriosis is a condition in which tissue similar to the uterine lining is found outside the uterus. When endometriosis affects the ovaries and forms cysts, these are known as ovarian endometriomas. They may contain thick, dark, old blood and are commonly called chocolate cysts.

When both ovaries are affected, treatment requires special attention to ovarian reserve. The surgeon must balance the goals of treating the cysts, controlling symptoms, reducing recurrence risk, and preserving functional ovarian tissue.

Potential symptoms and concerns include:

• Chronic pelvic pain and painful menstruation.

• Pain during sexual intercourse.

• Difficulty conceiving in some patients.

• Pelvic adhesions and distorted anatomy.

• Reduced ovarian reserve associated with the disease or its treatment.

Submucous Fibroid: Treating the Uterine Cavity

Submucous fibroids develop in the uterine muscular wall and extend towards or into the uterine cavity. Their position can make them particularly relevant in patients experiencing heavy menstrual bleeding or fertility-related problems.

Hysteroscopic myomectomy provides direct visualization of the uterine cavity and allows selected fibroids to be removed through the cervix. It is an important minimally invasive option for appropriately selected intracavitary fibroids.

Surgical Procedure: From Pelvic Assessment to Fibroid Removal

1. Preoperative evaluation

Before surgery, the clinical team assesses the patient's symptoms, medical history, pelvic imaging, ovarian cyst characteristics, uterine cavity, and fertility priorities. The size and location of both endometriomas and the submucous fibroid help determine the operative plan.

When fertility preservation is important, ovarian reserve assessment and discussion of reproductive options may be appropriate. The risks and benefits of operating on both ovaries should be explained before proceeding.

2. Anesthesia and patient preparation

The procedure is conducted under appropriate anesthesia. The patient is positioned and prepared to facilitate both laparoscopic and hysteroscopic access. The surgical team ensures that the equipment required for both components is available and functioning.

3. Laparoscopic entry and pelvic inspection

The laparoscope is introduced into the abdominal cavity after establishing safe access and pneumoperitoneum. The surgeon evaluates the uterus, both ovaries, fallopian tubes, pelvic sidewalls, and surrounding structures.

This initial inspection helps identify the extent of endometriosis, the presence of adhesions, and any anatomical distortion that may affect the dissection.

4. Adhesiolysis and exposure of both ovaries

Endometriosis may cause adhesions between the ovaries, uterus, fallopian tubes, bowel, and pelvic structures. Careful adhesiolysis is performed where required to restore exposure and allow controlled surgical access.

The surgeon must maintain awareness of the ureters, bowel, and pelvic vessels. Dissection should be performed with appropriate traction and countertraction, avoiding unnecessary injury to healthy tissues.

5. Bilateral endometrioma cystectomy

The ovarian cysts are approached individually. The cyst wall is separated from the surrounding ovarian tissue using a suitable dissection technique. The objective is to manage the endometrioma while preserving as much healthy ovarian cortex as possible.

In bilateral cases, ovarian preservation deserves particular attention. Excessive stripping, tissue trauma, and unnecessary thermal coagulation can adversely affect ovarian reserve. Hemostasis should therefore be achieved with careful tissue handling and an appropriate technique.

The choice of cystectomy or an alternative technique depends on the patient's clinical condition, ovarian reserve, fertility plans, and intraoperative findings.

6. Hysteroscopic examination

After the laparoscopic component, or according to the planned operative sequence, a hysteroscope is introduced through the cervix. The uterine cavity is inspected to identify the submucous fibroid and evaluate its relationship with the surrounding endometrium and myometrium.

7. Hysteroscopic removal of the submucous fibroid

The fibroid is treated using an appropriate hysteroscopic instrument and technique. Under direct visualization, the surgeon removes the intracavitary component while maintaining awareness of the depth of the lesion and the surrounding uterine wall.

Fluid management, visualization, bleeding control, and the risk of uterine perforation are important considerations throughout the procedure. The extent of removal depends on the fibroid's size, location, and intramural extension.

8. Final operative assessment

The surgical team reviews the operative fields and checks for bleeding or other complications. Tissue specimens are submitted for histopathological examination when appropriate. Postoperative monitoring and follow-up are planned according to the patient's condition and recovery.

The Importance of Ovarian Reserve Preservation

One of the most important learning points in bilateral endometrioma surgery is the preservation of ovarian function. Although cystectomy may help reduce recurrence and endometriosis-associated pain in selected patients, surgery can also remove or damage healthy ovarian tissue.

The risk deserves particular attention when both ovaries are involved. Patients should receive individualized counselling about ovarian reserve, fertility goals, possible fertility preservation options, and alternative treatment strategies before surgery.

NICE and ESHRE guidance emphasize considering fertility priorities and minimizing ovarian damage when planning endometrioma surgery. <Cite refs={["turn687146search0","turn687146search1","turn687146search9"]}/>

Why Hysteroscopic Myomectomy Is Important

Hysteroscopic myomectomy offers direct access to selected submucous fibroids without requiring an abdominal incision. Removing a fibroid that distorts the uterine cavity may be beneficial in appropriately selected patients, particularly when abnormal bleeding or reproductive concerns are present.

The surgeon must evaluate the fibroid's size, location, and depth before selecting the technique. Incomplete removal, excessive fluid absorption, bleeding, uterine perforation, and intrauterine adhesions are among the considerations that influence operative planning and follow-up.

Benefits and Considerations of a Combined Minimally Invasive Approach

When clinically suitable, managing bilateral endometriomas and a submucous fibroid during one operative episode may reduce the need for separate procedures and repeated anesthesia. It also allows the surgical team to address ovarian and uterine pathology within one coordinated treatment plan.

However, combined surgery is not suitable for every patient. The decision depends on the complexity of the endometriosis, the size and position of the fibroid, the patient's general health, operative duration, and fertility priorities. The safest approach is always individualized.

Surgical Education at World Laparoscopy Hospital

World Laparoscopy Hospital provides educational opportunities for surgeons and gynecologists interested in laparoscopic, hysteroscopic, and robotic surgery. Operative demonstrations such as this one help medical professionals study surgical anatomy, instrumentation, dissection techniques, tissue preservation, and decision-making in complex gynecological cases.

Prof. Dr. R. K. Mishra demonstrates the principles involved in combining different minimally invasive techniques to address two separate gynecological conditions. For trainees, the case highlights an important lesson: successful surgery requires more than technical skill. It also requires sound judgment, careful planning, anatomical understanding, and attention to the patient's long-term reproductive health.

Watch the complete video to explore the surgical approach to bilateral ovarian endometriomas and submucous fibroid removal, and to understand the role of advanced minimally invasive techniques in modern gynecological surgery.

Educational disclaimer: This video is intended for medical education and professional training. It does not replace supervised surgical training or individualized clinical decision-making.