Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

In this protocol, CO₂ fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

In light of the results of obtained, the CO2 fiber-laser represents one of the next best alternatives to the standard stripping technique in terms of ovarian preservation, pregnancy rates, and IVF outcomes.Simplicity and reproducibility makes this technique a viable alternative to cystectomy, even from gynecologist approaching the endometrioma without specific reproductive and/or endometriosis surgery skills.Any surgeon without surgical experience in the surgical treatment of ovarian endometriosis can use this technique.To begin, position the patient on the operating table with legs placed into stirrups.Position the patient in the lithotomic position, a variation of the supine position in which the legs are separated from the midline in a 30 to 45 degree abduction with the hips flexed until the thighs form an angle between 80 to 100 degrees.Establish a sterile field by cleaning the apex of the umbilicus, the abdomen, the perineum, and the top third of the thighs using a sponge soaked in antiseptic solution.Then, scrub with a gauze drenched in iodine solution, the vulva and the vaginal interior, up to the cervix, and discard it.Repeat the cleaning step three times.Using a new sponge drenched in an iodine solution, swab the anus twice and discard it.Dry the prepared external areas with a sterile towel and place the sterile drapes over them.Then, insert a urethral catheter for continuous bladder drainage.Using an anterior and posterior vaginal retractor, expose the cervix and insert the uterine manipulator into the cervix.Create a pneumoperitoneum by either a Veress needle inserted at an angle of 45 degrees in non-obese patients to 90 degrees in obese patients, or using the open technique by making a small one centimeter incision below the umbilicus on the midline.Keep the insufflation pressure between 12 to 14 millimeters of mercury.Insert a laparoscope and inspect the upper and lower abdomen.After positioning the patient in a slight Trendelenburg position, place the other laparoscopic access.For one step carbon dioxide fiber laser vaporization using an aspiration or irrigation device, drain the cyst content, irrigate, and inspect its inner wall.Using scissors, collect a biopsy of the cyst wall and send the sample for routine histological examination to confirm the diagnosis of endometriosis.Next, select the basic operation mode and set the device to fiber laser mode with the continuous wave and constant timed exposure mode at a power density of 13 to 15 watt.Avert the cyst with grasping forceps to expose the inner cystic wall and completely vaporize the inner wall with a carbon dioxide fiber laser in a radial way, starting from the center to the periphery, keeping the tip of the fiber at a distance of one centimeter from the cystic surface.After vaporization, do not suture the ovary.Carefully control any source of bleeding using the water test, or slightly reducing the pneumoperitoneum.After the surgery, carefully remove the uterine manipulator.Then, suture the fascia with a medium absorption rate braided suture size 0 and the skin with a quick absorption rate suture size 3-0.Place patches on all the incisions and remove the urethral catheter, the day after the surgical procedure.The ovarian reserve recurrence rate and fertility outcome after one step laser vaporization versus cystectomy in the treatment of ovarian endometrioma are shown here.In unilateral endometrioma, the change in antral follicle count of the operated ovary was significantly higher after one step laser of vaporization compared with cystectomy.Conversely, serum Anti-M