Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Summary

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Abstract

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.

We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

Introduction

Endometriosis is a chronic inflammatory condition defined by ectopic endometrial tissue¹. Patients with endometriosis commonly present with pain-related complaints and organ dysfunction related to the site of ectopic implantation, which may be anywhere in the body though is typically within the pelvis^2,3. Ovarian endometrioma, in which a cyst of endometriosis forms within the ovary, contributes to subfertility by multiple means, including depletion of the ovarian follicle pool, promoting an inflammatory environment, progesterone resistance, and impaired ovum release and capture

Protocol

The patient described provided written informed consent for the use and publication of medical data, operative video, and related images for educational and scientific purposes. The following protocol adheres to the human research ethics committee guidelines of Montefiore Medical Center and New York City Health and Hospitals Corporation.

Due to limitations of the available raw recording, not every step in the protocol could be fully documented in the video on this patient.

1. Preoperative evaluation

NOTE: Select patients who are candidates for a minimally invasive surgic....

Results

Table 1 shows results of our patient example. Total operation time was 251 min from anesthetic induction to extubation, with an estimated blood loss of 200 mL. The recovery period was uncomplicated. As she desired future pregnancy remote from the time of surgery, she began oral contraceptives. Histopathological examination revealed a right hydrosalpinx with paratubal cyst, bilateral endometriomas (4.5 cm and 3.7 cm), and ovarian tissue.

The surgery utilized a combination of fe.......

Discussion

Patients with diagnosed endometriosis commonly report pain or implant-related organ dysfunction, including infertility. Up to 50% of patients with endometriosis meet criteria for infertility²³. Ovarian reserve, measured via AMH levels, FSH levels around menses or an antral follicle count, is used to predict patient response to gonadotropin stimulation. Surgical management of endometrioma is known to decrease ovarian reserve²³. However, ovarian reserve continues to decline i.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Basic laparoscopy
1L bag 0.9% NaCl solution			Suction irrigation, hemostasis, lysis of adhesions
1-10% povidone-iodine			Sterile prep
2% chlorhexidine gluconate in 70% isopropyl alcohol for skin			Sterile prep
4% chlorhexidine gluconate			Sterile prep
5mm laparoscopic trocar and sleeve x 3	Covidien	ONB5STF	Diagnostic laparoscopy
12mm laparoscopic trocar and sleeve	Covidien	ONB12STF	Diagnostic laparoscopy and larger size facilitates specimen retrieval bag
CO2 insufflator	Stryker	620-040-504	Diagnostic laparoscopy
CO2 insufflator tubing	Stryker	620-030-201	Diagnostic laparoscopy
Electrosurgical generator	Covidien	VLFT10GEN	Diagnostic laparoscopy
Foley kit and urometer bag	Bard	153214	Diagnostic laparoscopy
Laparoscopic scope, 5mm 0 degree	Olympus	WA4KL500	Diagnostic laparoscopy
Laparoscopic scope, 5mm 30 degree	Olympus	WA4KL530	Diagnostic laparoscopy
Laparoscopic suction irrigation pool tip	Stryker	250-070-406	Suction irrigation, hemostasis, lysis of adhesions
StrykeFlow II suction irrigator	Stryker	250-070-500	Suction irrigation, hemostasis, lysis of adhesions
Suction tubing	Stryker	250-070-403	Suction irrigation, hemostasis, lysis of adhesions
Suction/vacuum source			Suction irrigation, hemostasis, lysis of adhesions
Cystectomy and Salpingectomy
10mm tissue retrieval bag	Covidien	173050G	Specimen retrieval bag to be used in 12mm laparoscopic trocar site
Atraumatic laparoscopic bowel graspers	Stryker	250-080-319	Lysis of adhesions, cystectomy, salpingectomy
Bipolar Cord	Stryker	250-040-016	Lysis of adhesions, cystectomy, salpingectomy
Endopeanut laparoscopic retractor	Covidien	173019	Lysis of adhesions, cystectomy, salpingectomy
Harmonic ACE +7 ultrasonic shears	Ethicon	HARH23	Lysis of adhesions, cystectomy, salpingectomy
Laparoscopic bipolar grasping forceps	Karl Storz	38951 MD	Lysis of adhesions, cystectomy, salpingectomy
Laparoscopic curved Metzenbaum scissors	Stryker	250-080-267	Lysis of adhesions, cystectomy, salpingectomy
Ultrasonic generator unit	Ethicon	GEN11	Lysis of adhesions, cystectomy, salpingectomy
Vasopressin solution (20 units in 50 to 100cc of injectable saline)			Cystectomy
Chromopertubation
10mg methylene blue in 150mL 0.9% NaCl solution			Pigmented solution for chromopertubation
ZUMI uterine manipulator/injector	Cooper Surgical	ZSI1151	Chromopertubation, diagnostic laparoscopy, lysis of adhesions
Hemostatic agents
Arista absorbable hemostatic particles 3g	Bard Davol	SM0002-USA	Hemostatic agent
Floseal gelatin thrombin matrix 5ml	Baxter	ADS201844	Hemostatic agent