Laparoskopi Pada Kasus Kista Endometriotic Bilateral

LAPAROSCOPIC
TREATMENT OF BILATERAL
ENDOMETRIOTIC CYSTS
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Page 1
Ultrasound (USG)
Presence of diffuse,
low level internal
echoes
Hyperechogenic foci
in the wall
Kissing ovaries
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Confirmed diagnose
Via laparoscopy and
histology
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Management of endometriomas
Hormonal treatment
Surgery
IVF - ET
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Surgical approach of ovarian

endometriosis
Surgical approach has to be chosen :
1. Coagulation of the site of eversion
2. Endometrioma Fenestration and
vaporization
3. Ovarian Cystectomy
4. Combined = Cystectomy and vaporization
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Ovarian cystectomy by laparoscopy

By Michel Canis
Avoid the opening of the cysts from the
anterior part of the ovary
Opening the cysts must be performed at the
attachment site zone of the cysts which
located between the ovary and the broad
ligament
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1st step : via adhesiolysis (the separation

of the ovary from the broad ligament).
During the adhesiolysis, the cysts will be
opened and you will be entered the cysts.
2nd step : performing the opening of the
cysts. During cystectomy, it will be easier
to grasp the ovarian cortex.
Make sure both plane of cleavage and
blood vassel were visible. Use coagulate
and apply traction and contratraction to
avoid severe bleeding
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Surgery and ovarian reserve

Risk of removal normal ovarian tissue and
ovocytes as endometrioma is surrounded
by a fibrotic capsule (which is an ovarian
tissue reaction)
By plane of cleavage can determined the
difference in macroscopic and microscopic
levels
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Surgical approach of ovarian

endometriosis
Endometrioma fenestration and ablation
Energy
Bipolar coagulation
CO2 laser
Plasma
In one step or three steps
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Ablation
Cyst wall vaporization = destroyed only
the endometriotic glands and the stroma
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3 steps treatment for large endometrioma

1.
2.
3.
4.
5.
Adhesiolysis
Aspiration of chocolate fluid
Vaporization of peritoneal lessions
Medical therapy GnRHa
Second look laparoscopy
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Combined excision and ablation

Recommended for very large cysts in
bilateral endometriotic cysts.
Partial cystectomy + ablation of the
deepest part of the cysts
One step therapy
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Excision + ablation : The Steps

1. Identified the ovary
2. The opening of the attachment between the
ovary and the broad ligament
3. After the separetion from the broad ligaments,
performed cystectomy by grasping the cysts
4. using traction and contratraction technique to
partially removed the cysts
5. After the cystectomy, performed ablation from
the deepest part of the cysts using CO2 laser
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Endometriotic cysts :
recommandations
Preoperative treatment
Pelvic pain : yes
Infertility : no effect on endometrioma size
Laparoscopy
Cystectomy or ablation or combined
Hemostasis : selective bipolar coagulation

Associated lessions : to be treated
Anti adhesion : antacid or dialobary
Post operative treatment
Infertility : GnRH-analog before IVF
Pelvic pain or no desire for pregnancy : OC pill to avoid the
recurrence
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Results of surgery?
Pregnancy rate : 60% of patiens obtain
spontaneous pregnancy after 9 12
months post op
Risk of recurrence
cystectomy = 5 8 %
ablation = 12 -22 %
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Cystectomy (excisional) vs ablative

Excisional surgery provides more
favourable outcome than albation with
regard to the :
Recurrence of endometrioma and symptoms
related to previous problems
Subsequent spontaneous pregnancy
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Surgery and ovarian reserve

Based on numerous research, indicates :
Statistically significant AMH decrease after
ovarian cystectomy
Ovarian reserve is injured by surgery
More reduction of ovarian reserve in women
operated for bilateral cysts
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IVF outcomes after surgery

Increased number of cancelled cycles
Decreased number of follicles, oocytes and
embryos
Conclusion = IVF outcome significantly
impaired after surgery
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Surgery in infertility associated to

endometriosis
In infertile women with AFS stage I/II
endometriosis, clinicans should perform
operative laparoscopy (excision or ablation),
rather than performing diagnostic laparoscopy
only increase ongoing pregnancy rates
Clinicans may consider CO2 laser vaporization
of endometriosis compared to monopolar
electrocoagulation higher cumulative
spontaneous pregnancy rates
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Clinicans should perform excision of the

endometrioma capsule, instead of
drainage and electrocoagulation of the
endometrioma wall increase
spontaneous pregnancy rates
In infertiloe women with endometriosis,
clinians should not prescribe adjunctive
hormonal treatment before or after surgery
may decrease spontaneous pregnancy
rates
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Thats all folks, thank you for

your attention
any questions?
Page 30

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LAPAROSCOPIC

Surgical approach of ovarian

Ovarian cystectomy by laparoscopy

1st step : via adhesiolysis (the separation

Surgery and ovarian reserve

Surgical approach of ovarian

In one step or three steps

3 steps treatment for large endometrioma

Combined excision and ablation

Excision + ablation : The Steps

Hemostasis : selective bipolar coagulation

Cystectomy (excisional) vs ablative

Surgery and ovarian reserve

IVF outcomes after surgery

Surgery in infertility associated to

Clinicans should perform excision of the

Thats all folks, thank you for

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