Strategies for Minimizing Ovarian Injury During the Surgical Treatment of Ovarian Endometriosis

Meticulous surgical technique and judicious use of electrosurgery may help minimize damage to the ovary when removing endometriomas,” demonstrates Natalia Llarena, MD, fourth-year resident, Ob/Gyn & Women’s Health Institute.

Dr. Llarena presented a video of an ovarian cystectomy and salpingectomy using a helium plasma device today at the American Society for Reproductive Medicine (ASRM) 2018 Scientific Congress & Expo. Fertility and Sterility Journal published the full abstract in its September 2018 issue.

“Endometriosis is a common condition, occurring in 10 percent of reproductive age women,” Dr. Llarena notes. There are several theories regarding the pathogenesis of endometriosis, with the best accepted being the retrograde menstruation theory, whereby menstrual blood refluxes into the abdominal cavity and implants onto the ovarian and peritoneal surfaces, she explains. An endometrioma then forms by an invagination of the ovarian cortex.

“Endometriomas may need to be removed due to pain or, in the case of large endometriomas, to improve access to the ovaries for IVF,” says Dr. Llarena. There are also data that suggest that removal of large endometriomas improves spontaneous conception rates. Still, she acknowledges, the risks and benefits of surgery always must be weighed.

“Surgical treatment of endometrioma has the potential to compromise ovarian reserve,” cautions Dr. Llarena. “In our video, we demonstrate surgical strategies to minimize ovarian injury and specifically highlight the utility of a helium plasma device during ovarian cystectomy.”

To reduce recurrence rates and optimize fertility, endometriomas should be enucleated rather than coagulated or vaporized, says Dr. Llarena. “Using a helium plasma device in place of a more traditional energy sources, like monopolar or bipolar electrosurgery, may reduce risk of damage to the ovary,” she says.

Methodology

The video demonstrates the surgical treatment of an endometrioma in a 25-year-old nulliparous patient with chronic pelvic pain. Preoperative MRI revealed an endometrioma and a hydrosalpinx. The ovarian cortex overlying the endometrioma is incised using a helium plasma device, and the endometrioma is dissected away from the ovarian parenchyma.

Hydrodissection assists in separating the cyst wall from the ovarian stroma, and plasma energy is used to separate fibrotic adhesions between the endometrioma and ovarian tissue. Bipolar electrosurgery is used sparingly to achieve hemostasis. Hydrodissection may assist in separating the cyst wall from the ovarian stroma once the correct plane has been reached. Traction counter traction is applied using Allis clamps to peel the cyst wall off the normal ovarian tissue. Traction must be applied close to the dissection plane to minimize tissue trauma.

A helium plasma device is then used to further incise the ovarian cortex. Bleeding occurs, as is often the case, due to the proximity of the area to the vascular supply of the ovary, and a bipolar device may be used sparingly to achieve hemostasis. Care is taken with tissue handling to avoid damage to ovarian follicles.

Conclusion

The expected benefits of surgery should always be weighed against the potential for loss of viable ovarian tissue. Ovarian function can be impacted by damage to gonadal vasculature from electrosurgery or removal of excessive ovarian tissue. Multiple studies have demonstrated a negative impact of adnexal surgery on ovarian reserve, particularly for excision of bilateral endometriomas.

This video demonstrates the surgical treatment of ovarian endometrioma and highlights the utility of the helium plasma device in ovarian cystectomy.