A How-To Guide for Endometriosis Surgery

A How-To Guide for Endometriosis Surgery

This document provides surgeons with tips for surgical treatment of endometriosis in women who wish to preserve fertility.

Key Points


  • This publication is the result of cooperation between the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES). The document details recommendations for different types of endometriosis surgery.


  • Surgery is one of the most utilized treatment options for women suffering from endometriosis. Endometriosis can manifest itself in a myriad of ways, and there are numerous treatment options for the disease as well. A comprehensive guide that will detail the technicalities of the best procedure for any given case and this publication hopes to be the guide.

What’s done here?

  • The organizations above formed a working group that sought to create the first guidebook, in a series of guides, containing recommendations about the technicalities of endometriosis surgery. More specifically, the operation for women of reproductive age.
  • The authors state that the recommendations in this document ought to be read alongside the evidence-based guidelines on the clinical management of the disease in question.
  • The recommendations in this publication are formed using expert opinion. The working group has also created a web platform that has videos for different surgical options for ovarian endometriomas. The link for this web platform is as follows: https://www.eshre.eu/surendo.

Key points:

  • The first section details anatomical considerations. It describes essential gynecological structures and processes. It also delineates the typical location of endometriomas and asks surgeons to consider the possibility of hydro-ureters and asymptomatic hydronephrosis.
  • General recommendations. The section urges surgeons to:
    • Assess the disease by identifying the cysts.
    • Conduct a bimanual examination, pelvic ultrasounds, and ovarian reserve tests.
    • If the surgeon believes the growth is malignant, they should analyze the serum tumor markers.
    • Receive consent from the patient. In other words, the patient should be knowledgeable about the surgery and associated risks.
    • Consult other specialties if necessary.
    • Be careful while handling the ovarian tissue.
    • Be cognizant of any damage to the ovarian reserve.
    • Anti-adhesion measures or ovarian suspension should be implemented to reduce adhesion formation postoperatively.
  • Initial stages of laparoscopic surgery for ovarian endometriomas: Urges surgeons to:
    • Inspect the relevant body parts, namely the pelvic organs, upper abdomen, and appendix.
    • Collect biopsies and peritoneal washings if warranted. Peritoneal washing is not recommended for presumed endometriomas.
    • Use three laparoscopic ports.
    • Use adhesiolysis to separate the ovary from the pelvic sidewall. The surgeon must visualize the ureter at this point as it is susceptible to damage.
    • Expose the cyst cavity in the case that the cyst ruptures.
    • Create an incision over the thinnest part of the ovarian endometriotic surface or antimesenteric border in the case that the ovary is not adherent.
    • Irrigate and observe the cyst cavity to determine malignancy. If a malignancy is suspected, that area should be biopsied for subsequent histological confirmation.
    • Remove cyst fluid and blood clots from the abdominal, pelvic cavity. The same procedure can also help the surgeon rule out hemostasis.
  • There are three options for conservative surgical treatment of ovarian endometriomas. These options are cystectomy, laser or plasma energy ablation, and electrocoagulation. The guidelines delineate the technical recommendations for each of the procedures.
  • There is a combined technique that uses excision and ablation. This technique prevents excessive bleeding. It also can prevent the removal and damage of ovarian tissue from the ovarian hilum.
  • There is an invasive two- or three-step approach that is used when large endometriomas are present. This approach can help with the management of large endometriomas. It can also reduce recurrence and limit ovarian reserve depletion.
  • Further considerations
    • A laparotomy is rarely recommended for benign ovarian endometriomas.  If laparoscopy cannot be done, the surgeon should only drain the endometriomas(s) and then prescribe a GnRH agonist (GnRHa) for three months. After a period of 3 – 6 months, the surgeon can operate again. The patient can also be referred to another institution.
    • The healthcare provider should discuss an oophorectomy with their patient. This should be a discussion if the patient has recurrent or large endometriomas or if there may be a malignancy.

Limitations of the paper:

  • There is a scarcity of evidence in this area, which is why most of this paper is based on the opinion of experts.

Lay Summary

The European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) recently published a document titled “Recommendations for the surgical treatment of endometriosis—part 1: ovarian endometriomas.” This publication provides surgeons with recommendations for the technical aspects of different surgeries used to treat endometriosis. This publication focuses on women with endometriosis who wish to get pregnant at a later date. This guidebook was created by a working group and is based on expert opinion. The authors recommend that this publication is used alongside evidence-based guidelines on the clinical management of the disease in question, namely endometriosis.

The document is split up into different sections. The first section is titled “anatomical considerations” and details the gynecological structures and processes that would be of interest in surgeries related to endometriosis. The next section is titled “general recommendations,” and this section provides surgeons with a checklist of recommendations that should be observed when surgically treating a woman with endometriosis. One of the significant recommendations described in detail in this section is the procedure for cyst identification. The next chapter discusses the initial stages of laparoscopic surgery for ovarian endometriomas. In this section, the reader is given various surgical tips that could make the entire process more efficient.

The publication then goes on to discuss the three options for conservative surgical treatment of ovarian endometriomas. These options are cystectomy, laser or plasma energy ablation, and electrocoagulation. The guideline provides advice on technical techniques for each of the procedures above. There is also a combined technique that uses excision and ablation. Additionally, the surgeon can use a two- or three-step approach for larger endometriomas. The document ends by providing advice pertinent to laparotomies, laparoscopies, and oophorectomies.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/29285022

ESGE ESHRE WES endometriomas surgery fertility laparoscopy laparotomy Cystectomy laser ablation plasma energy ablation electrocoagulation ophorectomy


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