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Gynecologic Surgery
of endometriosis

Endometriosis is a gynecological disease

In its initial form, endometriosis is a gynecological disease with several preferential locations; the peritoneum of the pouch of Douglas (located between the uterus and the rectum) and the vesico-uterine pouch (located between the bladder and the uterus), the utero-sacral ligaments (fibrous bands that attach the uterus to the back, at the sacrum bone level) and the broad ligaments (located below the ovaries and fallopian tubes).

Treatment of endometriosis lesions

These lesions are treated by excision. Removal involves the areas infiltrated by the disease, sometimes with the sacrifice of certain anatomical structures, such as the utero-sacral or round ligaments. Removal can be performed with scissors, ultrasound, plasma energy or by laser.

When they are millimeter-sized and less than 1mm thick, endometriosis lesions can also be destroyed by vaporization or ablation, with electric current, plasma energy or by laser. Vaporization leads to the disappearance of the lesions which transform into vapour. This technique is not suitable for deeper lesions, as only the superficial part is destroyed.

Deep endometriosis lesions

Deep endometriosis lesions are like an iceberg, a tip visible inside the pelvis (i.e. visible on laparoscopy), and a larger part hidden deep down (only visible on deep dissection).

As they go deeper, endometriosis nodules behave in a similar way to certain benign tumours, infiltrating nearby organs such as the vagina, the ureters or the rectum.

When they infiltrate the vagina, endometriosis lesions are visible with a speculum and can be palpated during a simple vaginal examination. Their removal involves the removal of a fragment of vagina, followed by suturing with absorbable sutures.

Endometriosis of the ovaries

Endometriosis can affect the ovaries, in the form of endometriosis cysts, called “endometriomas“. Unlike other types of benign cysts, endometriomas have a point of origin on the surface of the ovary, from which the cyst invaginates into the ovary, like a caterpillar into an apple. This point of invagination is usually (95%) attached by adhesions to surrounding organs.

Movement of the ovary during surgery leads to rupture of the adhesions, with immediate opening of the endometriomas. These are filled with a very characteristic viscous chocolate-coloured liquid, which contains broken down blood and cellular debris. This liquid is a favourable environment for the development of bacteria, which explains why endometrioma are likely to develop into abscesses, either spontaneously or following puncture.

The wall of an endometrioma has 2 distinct layers:

  • On the inside, a thin layer of endometrial cells, which by accumulation of the fluid contained in the cyst is responsible for its progression and probably for its recurrence
  • On the outside, a thicker layer (about 1 mm) of fibrosis, which adheres strongly to the underlying ovarian tissue. The absence of a cleavage plane, and even of a clear boundary under microscopy, explains why healthy ovarian tissue may be damaged when traction is exerted on this layer of fibrosis
Kyste endométriose ovaire
Fig3: microscopic view of the wall of an endometrioma

Surgery for endometriomas

Surgery for endometriomas is performed according to 4 main approaches:

  • Cystectomy, which involves removal of the cyst wall, i.e. the fibrous layer. This invariably involves removal of underlying ovarian tissue, resulting in a reduction to a varied extent, in the reserve of follicles in the operated ovary.
  • Ablation or vaporization, which involves in situ destruction of the endometrial tissue layer, without attempting to detach the fibrous tissue layer. Ablation is performed using laser or plasma energy without a downward diffusion of heat (thus protecting the underlying ovarian tissue).
  • Sclerotherapy or alcoholization is a further type of ablation. Alcohol at 95° is injected into the cyst and left in place for 10-15 min to destroy the inner endometrial layer, without affecting the underlying ovarian tissue.
  • Puncture-aspiration or simple drainageof endometriomas can be performed in women with an already impaired ovarian reserve, when the surgeon wishes to minimize the impact of surgical procedures on the ovaries. This technique is generally carried out before postoperative in vitro fertilization management in order to facilitate egg collection. It is however associated with a 100% recurrence rate, and for this reason the procedure is reserved exclusively for this purpose.
Endométriome ablation énergie plasma

Choice of surgical treatment for endometriomas

Endometrioma surgery is an example of personalized patient management.

The choice of surgical technique depends on several parameters:

  • Patient age: the younger the patient, the less intensive the ovarian surgery proposed will be, with preference given to sclerotherapy and vaporization
  • Desire for pregnancy: the desire to preserve the ovarian reserve favors vaporization techniques
  • Ovarian reserve: a satisfactory ovarian reserve allows use of cystectomy, whereas an impaired ovarian reserve favors simple drainage
  • Absolute indication for in vitro fertilization (destroyed or absent tubes, abnormal sperm parameters) favors simple drainage to preserve the ovarian reserve as much as possible
  • Advanced age (>40 years)without pregnancy desire: to reduce risk of recurrence cystectomy or even partial oophorectomy are the most suitable techniques
  • Cyst size: in the case of large endometriomas (>7 cm), cystectomy can be very harmful and vaporization is technically very difficult. For this reason, large endometriomas are best treated by sclerotherapy or by a combination of sclerotherapy and vaporization

The choice of surgical technique is discussed during the preoperative consultation, but the final decision is taken according to the patient’s wishes.

In the majority of cases, an ovarian reserve check-up is carried out before surgery, in order to ensure that ovarian insufficiency is not overlooked.

In young, single women with large, bilateral or recurrent endometrioma, fertility preservationby oocyte freezingis generally envisaged before surgery.

Despite complete surgery, 30% of women experience reforming of endometriomas within 2 years if menstruation persists. In most cases these are not recurrences, but the appearance of new cysts following ovulation. Blocking ovulation by taking a continuous pill reduces threefold the risk of recurrence .

For women wishing to become pregnant, the period of natural conception is generally limited to 9-12 months after periods begin, in order to achieve the best ratio between the probability of conception and the risk of recurrence.

in numbers


of women undergoing surgery for endometriomas by plasma energy vaporization or cystectomy become pregnant 3 years after surgery


of pregnancies after surgery are natural


of recurrences occur at 24 months after surgery in women not taking the pill


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2: Darwish B, Roman H. When Opportunity Knocks, Grab Your Chance: Shall Ablation Be Rehabilitated in the Treatment of Endometrioma? J Minim Invasive Gynecol. 2020 Aug 20:S1553-4650(20)30386-1. doi: 10.1016/j.jmig.2020.08.007. Epub ahead of print. PMID: 32828900.
3: Pluchino N, Roman H. Oocyte vitrification offers more space for a tailored surgical management of endometriosis. Reprod Biomed Online. 2020 Nov;41(5):753-755. doi: 10.1016/j.rbmo.2020.07.012. Epub 2020 Jul 18. PMID: 32819840.
4: Roman H. Laparoscopic Sclerotherapy of Large Endometriomas: Is It a Reasonable Approach? J Minim Invasive Gynecol. 2020 Sep-Oct;27(6):1223-1224. doi: 10.1016/j.jmig.2020.05.011. Epub 2020 May 22. PMID: 32446970.
5: Roman H, Chanavaz-Lacheray I; l’équipe Rouendométriose. Le Centre expert de diagnostic et de prise en charge multidisciplinaire de l’endométriose de Rouen : une expérience pilote française [The Rouen Expert center in the diagnosis and multidisciplinary management of endometriosis: A French pilot experiment]. Gynecol Obstet Fertil Senol. 2018 Jul-Aug;46(7-8):563-569. French. doi: 10.1016/j.gofs.2018.06.006. Epub 2018 Jun 22. PMID: 29937108.
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8: Chauvet P, Roman H, Gremeau AS, Canis M, Bourdel N. Prise en charge des endométriomes [Management of endometrioma]. Presse Med. 2017 Dec;46(12 Pt 1):1173-1183. French. doi: 10.1016/j.lpm.2017.10.004. Epub 2017 Nov 22. PMID: 29174658.
9: Stochino-Loi E, Darwish B, Mircea O, Touleimat S, Millochau JC, Abo C, Angioni S, Roman H. Does preoperative antimüllerian hormone level influence postoperative pregnancy rate in women undergoing surgery for severe endometriosis? Fertil Steril. 2017 Mar;107(3):707-713.e3. doi: 10.1016/j.fertnstert.2016.12.013. Epub 2017 Jan 12. PMID: 28089574.
10: Mircea O, Puscasiu L, Resch B, Lucas J, Collinet P, von Theobald P, Merviel P, Roman H. Fertility Outcomes After Ablation Using Plasma Energy Versus Cystectomy in Infertile Women With Ovarian Endometrioma: A Multicentric Comparative Study. J Minim Invasive Gynecol. 2016 Nov-Dec;23(7):1138-1145. doi: 10.1016/j.jmig.2016.08.818. Epub 2016 Aug 20. PMID: 27553184.
11: Motte I, Roman H, Clavier B, Jumeau F, Chanavaz-Lacheray I, Letailleur M, Darwish B, Rives N. In vitro fertilization outcomes after ablation of endometriomas using plasma energy: A retrospective case-control study. Gynecol Obstet Fertil. 2016 Oct;44(10):541-547. doi: 10.1016/j.gyobfe.2016.08.008. Epub 2016 Sep 21. PMID: 27665252.
12: Roman H. Politique de FIV systématique chez les patientes avec une endométriose profonde sévère et désir de grossesse : un support scientifique trop fragile pour des dommages collatéraux trop sévères [The policy of systematic first line IVF in patients with severe deep endometriosis and pregnancy intention: A thin scientific support with severe collateral damages]. J Gynecol Obstet Biol Reprod (Paris). 2016 Mar;45(3):211-3. French. doi: 10.1016/j.jgyn.2016.01.005. Epub 2016 Feb 18. PMID: 26900140.
13: Roman H, Quibel S, Auber M, Muszynski H, Huet E, Marpeau L, Tuech JJ. Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study. Hum Reprod. 2015 Mar;30(3):558-68. doi: 10.1093/humrep/deu354. Epub 2015 Jan 7. PMID: 25574030.
14: Roman H, Bubenheim M, Auber M, Marpeau L, Puscasiu L. Antimullerian hormone level and endometrioma ablation using plasma energy. JSLS. 2014 Jul- Sep;18(3):e2014.00002. doi: 10.4293/JSLS.2014.00002. PMID: 25392649; PMCID: PMC4208885.
15: Roman H, Auber M, Bourdel N, Martin C, Marpeau L, Puscasiu L. Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience. J Minim Invasive Gynecol. 2013 Sep-Oct;20(5):573-82. doi: 10.1016/j.jmig.2013.02.016. Epub 2013 Jun 10. PMID: 23759693.
16: Bourdel N, Roman H, Mage G, Canis M. Chirurgie des endométriomes ovariens: de la physiopathologie à la prise en charge pratique pré-, per- et postopératoire [Surgery for the management of ovarian endometriomas: from the physiopathology to the pre-, peri- and postoperative treatment]. Gynecol Obstet Fertil. 2011 Dec;39(12):709-21. French. doi: 10.1016/j.gyobfe.2011.07.051. Epub 2011 Nov 10. PMID: 22079743.
17: Mokdad C, Auber M, Vassilieff M, Diguet A, Bourdel N, Marpeau L, Roman H. Évaluation par échographie tridimensionnelle de la réduction du volume des ovaires après kystectomie des endométriomes [Assessment of ovarian volume reduction with three-dimensional ultrasonography after cystectomy for endometrioma]. Gynecol Obstet Fertil. 2012 Jan;40(1):4-9. French. doi: 10.1016/j.gyobfe.2011.07.038. Epub 2011 Oct 20. PMID: 22019254.
18: Roman H, Auber M, Mokdad C, Martin C, Diguet A, Marpeau L, Bourdel N. Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive. Fertil Steril. 2011 Dec;96(6):1396-400. doi: 10.1016/j.fertnstert.2011.09.045. Epub 2011 Oct 22. PMID: 22019124.
19: Auber M, Bourdel N, Mokdad C, Martin C, Diguet A, Marpeau L, Roman H. Ultrasound ovarian assessments after endometrioma ablation using plasma energy. Fertil Steril. 2011 Jun 30;95(8):2621-4.e1. doi: 10.1016/j.fertnstert.2011.04.090. Epub 2011 May 31. PMID: 21621773.
20: Roman H, Pura I, Tarta O, Mokdad C, Auber M, Bourdel N, Marpeau L, Sabourin Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study. Fertil Steril. 2011 Apr;95(5):1853-6.e1-4. doi: 10.1016/j.fertnstert.2010.11.038. Epub 2010 Dec 17. PMID: 21168130.
21: Roman H, Tarta O, Pura I, Opris I, Bourdel N, Marpeau L, Sabourin JC. Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas. Hum Reprod. 2010 Jun;25(6):1428-32. doi: 10.1093/humrep/deq069. Epub 2010 Apr 8. PMID: 20378613.

Get support and advice from a specialist in gynecological endometriosis

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Last updated on May 4, 2021 @ 17:15