Ten Principles for Safe Surgical Treatment of Ovarian Endometriosis.

STUDY OBJECTIVE: To show a step-by-step laparoscopic approach for excision of an ovarian endometrioma following surgical principles for safety and maximal preservation of ovarian function. DESIGN: Video. Medical management of ovarian endometriomas is not recommended. Operative laparoscopy is the treatment of choice. Although considered a simple procedure, ovarian cystectomy requires a precise and correct technique in order to preserve ovarian function. SETTING: A private hospital. PATIENT: An asymptomatic, 27-year-old woman with ultrasound imaging suggesting a 6.2 × 5.4 cm left endometrioma. Additional findings of endometriotic implants were noted in the posterior aspect of the left broad ligament, retrocervical region, Douglas pouch, and left round ligament. INTERVENTIONS: After trocar insertion, standard inspection of the pelvic cavity with identification of endometriosis lesions and adhesions was performed. The endometrioma was drained with direct trocar puncture to avoid spillage of the endometriotic contents. Cyst aspiration and saline cleaning were executed. After drainage, a cold cut was performed at the puncture site for better identification of the cyst capsule. Through gentle traction and countertraction, the capsule was peeled from the ovarian cortex, preserving as much ovarian tissue as possible followed by careful hemostasis with a bipolar instrument. The ovary is fixed, anatomy re-established, and concomitant pelvic endometriosis resected. We aim for complete surgical excision in order to avoid leaving disease behind. The ovarian edges were reapproximated using simple interrupted stitches. MEASUREMENTS AND MAIN RESULTS: The total procedure time was 40 minutes. CONCLUSION: Laparoscopic endometrioma stripping offers an effective option for ovarian endometriosis treatment, reducing recurrence and being reproducible by gynecologic surgeons after proper training.

Clinical characteristics and location of lesions in patients with deep infiltrating endometriosis using the revised Enzian classification

Objective: To describe the clinical characteristics and location of lesions in patients with deeply infiltrating endometriosis using the revised Enzian (rEnzian) classification. Material and Methods: The clinical records of 60 patients undergoing laparoscopy for deeply infiltrating endometriosis at Hospital Civil de Culiacán, Sinaloa and Hospital San Javier, Jalisco, Mexico, were reviewed. Age, body mass index (BMI), number of pregnancies, childbearing, previous abortions, laparoscopic suggestion (pelvic pain, bleeding, infertility), and size and location of the lesions were assessed according to the rEnzian classification. Results: The mean age of the patients was 30.5 years. The mean BMI was 25.6 kg/m2. Sixty-eight percent were nulliparous and 13% had at least one birth. Eighty-five percent had pelvic pain and 8.3% had infertility. Seventy percent (n=42) of the women had ovarian endometriomas (middle compartment); uterosacral and the torus uterinus ligaments were affected in 23.3%, rectum and sigmoid colon in 35% (posterior compartment), and the appendix and small intestine in 3.3%. According to the rEnzian classification, the most affected compartment was C2 (rectum and sigmoid colon with 1-3 cm lesions). Conclusion: Pelvic pain was the main symptom of patients with deeply infiltrating endometriosis, mainly in nulliparous women. According to the rEnzian classification, the C2 compartment was the most affected (rectum and sigmoid colon).