Endoscopic methods (laparoscopy and hysteroscopy) are valuable tools in the diagnosis and treatment of infertility. Endoscopic (hysteroscopic-laparoscopic) surgery, by widening its range of application, has evolved into the treatment of choice for infertility cases, while it tends to minimize the indications for traditional laparotomy.

Hysteroscopy allows us to view the cavity of the uterus, i.e. the location that will receive the developing embryo and will support its development.

Laparoscopy is useful for examining the internal female reproductive organs (i.e. uterus, fallopian tubes and ovaries).

Salpingoscopy allows us to view the intraluminal portion of the uterine tubes, although this method was not widely accepted, it is rarely used and is not part of everyday clinical practice.Some pathological conditions of female genital organs cannot be diagnosed with any other method but by hysteroscopy (e.g. endomitritis) or laparoscopy (e.g. peritoneal endometriosis or adhesions). It is possible that these conditions remain undiagnosed for a long time period in a significant percentage of infertile women. Many of these conditions can be identified and treated during the same operating procedure under anaesthesia.A main principle of endoscopy is the ability for immediate visualisation of the formations and colorations of the human body cavities with a minimum amount of distortion (J. Hamou). Experience and knowledge in this field are necessary, as well as the right selection of technical equipment. The selection of the cold light laparoscope, the camera and the tools used reflect the experience of the surgeon. There are many differences in the various types of equipment that are used and it is very important to make the best selection.

Hysteroscopic and laparoscopic surgery represent a technological revolution in surgery. The surgeon and his colleagues operate by viewing the image on the monitor via a camera attached to the laparoscopy probe. Laser beams, electrosurgery units, numerous special tools and endoscopes comprise the technological equipment used. As well as specialized scientific knowledge and experience, the surgeons must have a sound technical knowledge of the special equipment.Pregnancy rates are significantly higher following hysteroscopic correction of pathological conditions of the uterine cavity.

Endoscopic operations have an advantage over older methods of open surgery because:

• Hospitalization lasts for one day only
• Laparotomy is avoided (open surgery)
• The danger of development of post-operational lesions is avoided
• Post-operational pain is minimal
• There are no post-operational scars on the skin of the belly
• The duration of the operation is significantly smaller compared to laparotomy
• The opening of the uterine cavity is avoided in hysteroscopic surgery
• The return to everyday life and work is quick

This examination is useful for the diagnosis of the physiology or the pathology of the uterus and the endometrium.

The possible pathologies that can be diagnosed include (Image1 –Image 9):

• Endometrial adhesions (symphyses) (Image 1).
• Endometrial or cervical polyp (Image 2).
• Submucosal fibroids (Image 3).
• Congenital anomalies of the uterus (uterine septum, unicornuate uterus, uterus with double cervix, T-shaped uterus etc.) (Image 4, Image 5).
• Inflammation of the endometrium (endometritis) (Image 6). Endometritis has a characteristic hysteroscopic appearance, especially during the proliferative phase of the cycle. We can distinguish the characteristic spots, while there is hyperhaemia of the endometrium. The endometrium also appears covered in mottled white gland openings.
• Adenomyosis (Image 7, Image 8) During hysteroscopy the appearance of adenomyosis is characterized by brown or black spots similar to these observed laparoscopically in endometriosis.
• Osseous metaplasia (Image 9): it is a rare hysteroscopic finding that is associated with unexplained infertility.
• Scars in the endometrim from previous curretage or others procedures.
• Hyperplasia of the endometrium.
• Leftover tissue after prengnacy.
• Malignant neoplasias of the uterine cavity.

Image 1 – Endometrial adhesions (hysteroscopic image)
Image 2 – Endometrial polyp (hysteroscopic image)
Image 3 – Submucosal uterine fibroid (hysteroscopic image)
Image 4 – Uterine septum (hysteroscopic image)
Image 5 – Unicornuate uterues (hysteroscopic image)
Image 6 – Endometritis (characteristic hysteroscopic image)
Image 7 – Adenomyosis (hysteroscopic image)
Image 8 – Adenomyosis (hysteroscopic image)
Image 9 – Osseous metaplasia (hysteroscopic image)

Hysteroscopy offers the possibility to directly observe the uterine cavity for an accurate diagnosis. Using hysteroscopy we can examine:

• The morphology (size and shape) of the uterine cavity (Image 2)
• The uterine openings of the fallopian tubes (Image 3)
• The structure and development of the endometrium
• The cervical tube (endocervix) (Image 3)

During hysteroscopy, the openings of the fallopian tubes, unless they are blocked or occluded, show a pre-salpingeal septum that looks like a thin semi-transparent membrane. Hysteroscopy has an advantage over hysterosalpingography in sensitivity and specialization in investigating infertility and repeated miscarriages. Hysteroscopy is a valuable tool for the diagnosis and treatment of infertility, as 62% of infertile women has been found to display endometrial cavity pathology.

Image 1 – The cervical tube (endocervix). (hysteroscopic image).Image 2 – The uterine cavity. (hysteroscopic image).Image 3 – The uterine openings of the fallopian tubes. (hysteroscopic image).

 

When it is recommended in infertility?

Hysteroscopy is recommended:

• For the specification of hysterosalpingography or ultrasound findings concerning adhesions, polyp, fibroids, congenital abnormality.
• After repeated miscarriages.
• After two consecutive unsuccessful IVF cycles.
• In history of miscarriages, abortions and operations to the uterine cavity.
• To investigate unexplained infertility combined with laparoscopy.
• As a routine method before IVF (it is recommended by several specialists), especially in the absence of hysterosalpingography.

A significant percentage of women with normal hysterosalpingography demonstrate endometrial cavity pathology when subjected to hysteroscopy.

Hysteroscopy- When is it performed?

Hysteroscopy is best to be performed in the immediate postmenstrual period (8th-12th day of menstrual cycle) in order to assess the quality of the endometrium that is during its proliferative phase. Hysteroscopy should not be performed during the secretory (second) phase of the menstrual cycle in order to avoid affecting an already established pregnancy.

Preparation?

When intra-venous anaesthesia or sedation is administered, the necessary precautions as in any surgical procedure must be taken, i.e. abstaining from oral food and fluid intake (especially milk).

Detail of a micro-hysteroscope Hamou of a 2.9 mm diameter (K. Storz). Magnification ability x 60 (EUGONIA archive).

It is a modern, safe and fast method of surgically treating benign pathological conditions of the uterus. It is harmless and effective when executed by experienced surgical teams with cutting-edge technical knowledge. It is a method of choice in infertility cases related to these conditions. The advantages are similar to those of laparoscopic surgery. Hysteroscopy is performed with the use of a camera-hysteroscope, advanced medical technology equipment, special thin tools and electrosurgery units. The surgery time needed is substantially reduced when compared to a laparotomy procedure. In addition, it is internationally acceptable that the pregnancy results are significantly higher following the correction of any endometrial pathology with hysteroscopic surgery.In order to perform hysteroscopic surgery, it is necessary to distend the uterine cavity which can only be achieved with distension fluids. The distension fluids may be crystalloid (e.g. normal saline solution) which are electrically conductive and colloid (e.g. glycine, Purisol, etc.) which are non conductive. 

Detail of a continuous flow source (EUGONIA archive).

 

 

It is evident that hysteroscopic surgery application requires a great deal of experience and specialisation of the surgical ream, while it is also essential to perform a full pre-operative check along with the necessary pre-operative preparation.The necessary medical equipment include a series of hysteroscopes, flow source, tools and cold light sources, infusion-suction devises and electrosurgery units.However, the most important “tool” for the specialised surgeon are his/her surgery colleagues, i.e. the second surgeon participating, the experienced anaesthetist and the specialised surgery personnel. The minimum conditions that must be met in order to proceed with this surgery are a clear field of view, which is achieved with the special continuous flow sources and the maintenance of a constant intra-uterine pressure, always within the internationally accepted limits.The Endomat electronic fluids infusion-suction device (J. Hamou invention) achieves a constant intra-uterine pressure that can be pre-selected, while it automatically regulates the infusion and suction of the fluid distention means.The electrosurgery units are necessary tools for performing a hysteroscopic surgery and they can be monopolar or bipolar. The bipolar electrosurgery units (Versapoint) are the modern approach since they provide safety of the bipolar current and the possibility to use the safe saline solution versus the non-electrolytic colloid solutions (glycine, sorbitol) which have side-effects.Hamou, who was one of the pioneers of hysteroscopic surgery, considers that the minimum conditions that must be met are a very good knowledge of:

• The techniques of diagnostic hysteroscopy,
• The capabilities and limitations of the all tools and units used,
• The indications, contra-indications and complications of the method
• The various distension means of the uterus and their side-effects,
• The capabilities and complications of electrosurgery.

Hysteroscopic surgery is applied:

• For the lysis of endometrial adhesions
• For the removal of endometrial or cervical polyps
• For the resection of the uterine septum
• For the removal of submucosal fibroids
• For the removal of the osseus lamellae (bony fragment) of osseus metaplasia
• For the removal of foreign bodies (e.g. intrauterine contraceptive coils)

Endometrial adhesions are responsible for subfertility, recurrent miscarriages, secondary amenhorroea (absence of a menstruation), haematometra (accumulation of blood within the uterine cavity) and oligomenhorroea (abnormally infrequent menstruation or abnormally scanty blood flow during menstruation). The pathophysiological are the ablation/curettage of the uterus, especially after delivery and septic miscarriage and more rarely endometritis caused by tuberculosis. A medical history that shows absence of menstruation following ablation raises a serious clinical suspicion and such finding are confirmed with hysterosalpingography and hysteroscopy.Endometrial adhesions are an important cause of subfertility and should be treated with hysteroscopic surgery techniques under immediate guidance and vision.The blind separation of endometrial adhesions with scrappers is a procedure that belongs to the past. These days, the treatment of choice for endometrial adhesions is the hysteroscopic separation under immediate vision and guidance.

Lysis of an endometrial adhesion with hysteroscopic scissocrs under immediate vision and guidance.

The results of separating the adhesions depend on their  extend, location, thickness and their morphology (thin and transparent, solid and fibrous). Also, the results of such a procedure with regards to pregnancy success and reappearance of a normal menstrual cycle are usually excellent.

VIDEO: Lysis of endometrial adhesions.

An exception to such good results after hysteroscopic surgery is Asherman syndrome, which is characterized by the extended adhesion of the uterine cavity walls: this results to the absence of a uterine cavity and the absence of a menstruation. In 1948, Asherman described as "traumatic amenorrhoea" the secondary amennorrhoea that results following a traumatic ablation of the uterus, especially after parturition or septic miscarriages. Restoring the uterine cavity after lysis of the extended adhesions in Asherman syndrome is exceptionally difficult or even impossible.

Uterine septums are the most common congenital anomaly of the uterus. The congenital anomalies of the uterus do not constitute a certain or the only factor of subfertility, though they may affect the pregnancy.

Various phases of hysteroscopic section of the uterine septum.

 

In the past, their surgical treatment included laparotomy, section of the uterus and the septum and suture of the uterus with the Strassmann and Jones techniques etc. Nowdays, the section of the septum is performed with hysteroscopic surgery which is a treatment of choice in order to create a uniform cavity in the septate (double) uterus. The creation of a normal uniform cavity after surgery is impressive and the development of epithelium is exceptional. Post-operative check includes hysterosalpingography and hysteroscopy.

In some cases of bicornuate uterus that the development of a pregnancy may be affected, plastic surgery of the uterus according to the Strassmann-Jones techniques that are performed with laparotomy may be decided. An alternative solution for such cases may be the limited hysteroscopic section of the point of connection of the two horns, in order to achieve a limited extension of the uterus.

This section takes place under laparoscopic guidance and the results are checked after three months with hysterosalpingography and hysteroscopy.

Bicornuate uterus:
Α. Hysteroscopic appearance of the point of connection of the two horns.
Β. Commencing limited section with Versapoint-Twizzle.
C. Final result.

Fibroids (also known as leiomyomas) are benign tumors of the uterus and they may be submucosal, intramural and subserosal according to their position within the uterus.

Intramural and subserosal fibroids are usually asyptomatic, unless they are too big and cause tension.

Submucosal fibroids are the type of fibroid that protrude fully or in part in the uterine cavity and they distort it. Submucosal fibroids may result in subfertility and their main symptom is anomalous haemorrhage from the uterus. They can be diagnosed with hysterosalpingography, transvaginal ultrasound, sonohysterography, computed tomography and magnetic resonance imagining. Hysteroscopy is however the diagnostic tool of choice.

Classification of submucosal fibroids

The classification of submucosal fibroids is essential for their treatment with hysteroscopic surgery. Submucosal fibroids are classified according to their degree of protrusion in the uterine cavity in:

• Fibroids that fully protrude inside the uterine cavity.
• Submucosal fibroids that their larger part (larger than their 3/5) protrudes inside the uterine cavity.
• Submucosal fibroids that their smaller part protrudes in the uterine cavity (smaller than their 2/5) and their larger part is located in the uterine wall (larger than their 3/5 in the myometrium).
• Multiple (more than 2) submucosal fibroids.
• Pedunculated submuscosal fibroids, of which a special category are the ones that protrude through the cervix.

Small submucosal fibroids of the front wall of the uterus (hysteroscopic image).

A large submucosal fibroid that protrudes almost fully in the uterine cavity.

Submucosal fibroids- Criteria for treatment

VIDEO: Hysteroscopic removal of a submucosal fibroid.

It goes without saying that the fibroids that protrude fully or in their largest partin the uterine cavity must be resected during hysteroscopy.

Determining factors for the hysteroscopic surgical treatment of fibroids are the precise diagnosis prior to surgery and their classification under transvaginal ultrasound that defines their size, their location, as well as their percentage relation to the wall and the perimetrium. These criteria are supplemented by the diagnostic hysteroscopic check that precedes their hysteroscopic resection. In the secondary criteria are include their hysterosalpingographic appearance.

Hysteroscopic resection of a submucosal fibroid of the uterus. The wire loop of the resectoscope can clearly be seen, as well as the sections on the fibroid.

Pre-surgical administration of GnRH analoges for two months, reduces the size of the submucosal fibroids and eases their surgical removal with hysteroscopy and their blood supply. On a technical level, the hysteroscopic removal of submucosal fibroids is performed with the help of the resectoscope wire loop. Sections of the fibroid are gradually removed with the resectoscope until the entire fibroid has been removed.

It is a rare finding that is related to secondary subfertility. Less than two hundred cases have been reported in scientific literature internationally and their diagnosis may often be missed.

Mayer, a German pathologist (1901) was the first to report the presence of bony tissue in the uterus. Following that, there have also been reports by Thaler H. (1923), De Brul et al., (1956), Frydman R. και Hamou J. (1985,1991), Edwards R.G. (1985), Acharya et al., (1993). A similar case report has been published by our Unit in an international scientific journal. (Osseous Metaplasia: Case report and review, T. Lainas et al., Fertility and Sterility, Vol. 82, No 5, November 2004, 1433-1435).

Two main hypotheses have been advanced to account for such formations. The first hypothesis accounts for the majority of the cases reported and it suggests that osseous metaplasia has resulted from osseous foetal tissue that remained in the uterine cavity following an abortion that has occurred at >3 months of gestation. The second hypothesis represents a true osseous metaplasia, similar to that which occurs after the calcification of fibroids and it has been observed in women with no pregnancy history.

This condition is usually asymptomatic. It may result in uterine haemorrhage, pelvic pain, dysmenorrhoe etc.

During transvaginal ultrasound, it appears as an intrauterine device (IUD; spiral).

Osseous metaplasia.

It has a characteristic flat coral-like hysteroscopic appearance.

The removal of the osseous lamellae is usually performed with the wire loop of the resectoscope. It may also be performed with hysteroscopic scissors and a grasper.

Histological examination following the desalination of the plaque showed mature bone tissue.

It is wise to re-examine the uterine cavity after two months with hysteroscopy.

Following the removal of the osseous lamellae, fertility can be restored if there are no other subfertility factors present.

Removal of the osseous lamellae (bony fragment) (hysteroscopic image).

The osseous lamellae following its hysteroscopic removal.

Endometrial polyp on the right uterine horn, that obscures the view of the opening of the right Fallopian tube.

Endometrial polyps are usually asyptomatic, benign little tumors of the uterus and may be responsible for the anomalous uterine haemorrhage or be found during intravaginal ultrasound or hysterosalpingography.

Polypoid hyperplasia of the endometrium (hysteroscopic image).

Endometrial polyps may vary in shape, size and number and numerous times may also come with endometrial hyperplasia, from which they should be differentiated when diagnosed (as for example with polypoid hyperplasia of the endometrium).

VIDEO: Removal of polyp with Versapoint.

Polyps that are seen during the secretory phase of the cycle do not need any treatment. On the contrary, persistent mucosal or fibroid polyps can be removed with hysteroscopic surgery. Their relation to subfertility is disputed.

The endometrial polyp will be removed with hysteroscopic scissors.

If the endometrial polyp is less than 2 cm, it does not seem to negatively affect the pregnancy chances, it may though increase the chances of pregnancy loss (Lass et al., 1999). In the same study, it is also mentioned that in assisted reproduction cycles, the practice of embryo freezing and the embryo transfer in a following cycle when the need for polyp removal arises may possibly increase the birth rates.

It is performed without the classic 10-20 cm section (laparotomy), with four small holes (three holes of 0.5 cm diameter each at the level of the pubic region and one main 1 cm hole on the umbilicus). The procedure is performed using a laparoscope connected to a laser CO2 unit and special tools.

The use of CO2 laser beams confers accuracy in the section and vaporization (i.e. conversion of the excised tissue from solid to gas), qualities that are considered ideal for the treatment of infertility-related conditions.

A necessary requirement is the excellent technical knowledge of laser laparoscopy of the surgical team.

Which operations are performed laparoscopically?

The technique can be applied in the entire range of gynecological surgical operations:

• Treatment of endometriosis – vaporization of chocolate cysts
• Fallopian tube plastic surgery, fallopian tube opening
• Adhesion lysis
• Removal of ovarian or paraovarian cysts
• Ectopic pregnancy with retention or removal of the fallopian tube
• Removal of uterine fibroids
• Treatment of chronic pelvic pain using L.U.N.A.

Vaporization using SwiftLase has an advantage over diathermy. With the addition of SwiftLase, the depth of vaporization is smaller, known and very particular from histological studies, and does not leave carbon residues.

Laparoscopic removal of myomas must be performed in selected cases of subserous and interstitial myomas. The operation is performed based on specific criteria. The indications for laparoscopic myomectomy have been increased in the past decade, as its advantages over traditional laparotomy have been recognized.

VIDEO: Myomectomy

Myomas are generally benign tumours of the uterus and appear during the reproductive age of a women at a 20% rate. They may be single or numerous, while their size ranges from a few mm to several cm. Depending on their localization, they are classified as interstitial, subserous or submucosal, with or without a stem.

Laparoscopic image of subserous uterine fibroids.

Laparoscopic image of subserous uterine fibroids.

The number, size, localization, the raletion to the wall, the absence of projection in the uterine cavity, and the absence of degeneration are some of the criteria for laparoscopic ablation. Pediculated and large subserous myomas are easily removed laparoscopically. Very large, multiple myomas at a difficult location or near large vessels, the ureter, the oviduct and those that due to size occupy the wall and project into the cavity, are difficult to remove laparoscopically. For myomas situated in the broad ligament the surgeon must be experienced.

Submucosal myomas can be treated with hysteroscopic surgery (see relative section). Interstitial and subserous myomas, which are the majority of myomas, laparoscopic surgery has good results.

Careful preoperative examination is necessary to decide which patients should undergo laparoscopic myomectomy, because it is impossible to pulpate the uterine wall completely. Preoperative examination includes transvaginal anf pelvic ultrasound, examination of the intrauterine cavity using hysteroscopy or hysterosalpingography, and general blood test including hematocrit measurement. Ultrasound examination includes measurement of uterine size, number, size and location of myomas and their type.

Also, it is very useful to count the distance between myoma and endometrium, and the exclusion of the presence of adenomyoma. The adenomyoma is difficult to remove from the myometrium and therefore laparoscopic surgery is not recommended. Diagnosis of adenomyomas is mainly pathoanatomical, but can also be performed using ultrasound, colour doppler or MRI.

Hysterosalpingography is useful for the evaluation of the size of the uterine cavity and state of the oviducts is cases of infertility. Basic hormone tests (FSH, LH, PRL, Ε2, TSH on the 3rd day of the cycle) to identify the biological age of the ovaries, and semen analysis complement the infertility investigation. Indications for laparoscopy are related to the number, size and type of myomas. A metaanalysis suggests maximal diameter 5 cm and maximal number 2 myomas per patient.

According to J. Dubuisson is that laparoscopic myomectomy should not be performed if 2-3 myomas are identified using ultrasound, or if the diameter exceeds 8-10 cm.

The localization of the myoma may cause some difficulties. The presence of interstitial myoma of 4-7 cm in diamater, which project in the uterine cavity, causes questions regarding its laparoscopic ablation.

Removal (enucleation) of uterine myoma laparoscopically with the use of CO2 laser.

An incision is perfomed over the myoma using laser CO2 and the myoma is removed according to the principles of atraumatic microsurgery, avoiding bleeding. The cavity is closed using special endoscopic sutures. The myoma is removed following its fragmentation using a special laparoscopic tool (morsellator). The operation end with careful washing of the peritoneal cavity with saline.

See also:
Submucosal fibroids

Management of ectopic pregnancy using laparoscopic surgery is nowadays the method of choice. Until the 1970s, laparotomy was used due to the inability of early diagnosis, resulting in the rupture of the ectopic pregnancy.

VIDEO: Ectopic pregnancy on right oviduct. Salpingοtomy, fetal removal and retaining of the oviduct.

Early diagnosis is now performed prior to rupture, using beta hCG levels combined with ultrasound examination. Laparoscopic verification is rarely needed. Early diagnosis and laparoscopic surgery have nearly eliminated the disease and mortality due to ectopic pregnancy, and have improved significantly the rate of post-operating infertility.Contraindications for laparoscopic surgery, as reported 20 years ago (Mage G., Canis M., Bruhat M.A) include:

• Absolute contraindications: interstitial pregnancy, shock, opisthoperitoneal hematocele, and contraindication of general anesthesia.
• Relative contraindications: hemoperitoneum >15000 ml, obesity, extensive adhesions.

VIDEO: Ectopic pregnancy on both oviducts. Salpingotomy, removal of fetus and retaining of the oviducts.

Laparoscopic surgical treatment of ectopic tubal pregnancy can be either conservative, with longitudinal salpingotomy, aspiration of the fetus and retaining of the oviduct, or radical, with excision of the oviduct.The choice of laparoscopic treatment in based on criteria, but also on the experience and training of the surgical team. The criteria include history of infertility, prior or repeated ectopic pregnancy, salpingoplasty, site of implantation (isthmus, ampulla, infundibulum), bilateral ectopic tubal pregnancy, and risk of oviduct rupture. Based on the score that results from these criteria it is decided whether to retain or remove the oviduct.a) ) In the case of oviduct rupture, laparoscopic surgery involves a longitudinal section 10-15 mm is above the fetus, removal of the fetus using flushing with saline, aspiration of the fetus away from the wall of the oviduct. The oviduct is examined for bleeding and the wall remains open. Rarely are sutures needed. At the end of the operation the pelvis is flushed with saline, all fetal elements are removed from the pelvis and the other oviduct is examined.Post-operating monitoring includes measurement of hCG levels 2 days after the operation, and then every 2 weeks until hCG is no longer detectable.b) In the case of oviduct removal, the operation is performed using bipolar diathermy for hemostasis, and the excision of the oviduct is done using laser CO2 or scissors. The section is performed very near the oviduct taking care not to damage the blood supply of the ovary.See more: Ectopic pregnancy

Tubal and peritoneal factor is the main cause of subfertility in 11-30% of subfertile couples. It may refer to tubal inflammatory damage, endometriosis and adhesions of the uterus and the pelvis in general.

Tubal pathologies include:

• adhesions,
• occlusion of the isthmus (cornual-isthmic tubal occlusion),
• partial occlusion of the infundibulum (prefimbrial phimosis),
• total occlusion of the infundibulum (hydrosalpinx).

It is reminded that the fallopian tube consists of four parts: the interstitial or conual portion, the isthmus, the ampulla, the infindibulum and the fimbria.

Procedures for the restoration of such damage include lysis of the adhesions, fimbrioplasty, salpingostomy and tubotubal anastomosis. Nowdays, these procedures have limited application due to high pregnancy rates after assisted reproduction which bypasses the tubal factor. These procedures in the past had a wide application and aimed in treating tubal factor subfertility.

Nowadays they are considered an alternative solution to assisted reproduction and they are performed with laser laparoscopic surgery, offering satisfactory natural conception pregnancy rates in certain cases.

Image 1. Adhesions (Laparoscopic image).

Adhesions may be a cause of subfertility (tubal-peritoneal aetiology) and probably pelvic pain. It is possible to affect one or more organs of the pelvis and they are usually located between the uterus, the fallopian tubes, the ovaries, the peritoneum, the intestine, the vermiform appendix and the omentum. Usual aetiology includes pre-existed inflammation and procedures in the pelvic area.

VIDEO Fitz-Curtis-Hugh syndrome. The right hypochondriac region can be observed with "violin-string" adhesions.

Image 2. – Extended pelvic adhesions, a result of severe inflammation (laparoscopic image).

Adhesions may be thin transparent and avascular (Image 1.) and solid and fibrous ones (Image 2.) that usually contain blood vessels.

The thin and transparent adhesions may easily be lysed with laser CO2 (Image 3.), while solid and fibrous ones that sometimes permeate all the organs in the pelvis and alter completely the anatomical relations, need more attention and experience.

Pregnancy rates after laser laparoscopic lysis of the adhesions are estimated around 55% according to some studies.

Image 3
A: The thin and transparent adhesions can easily be removed with laser CO2.
Β: The lysis of extended adhesions demands great experience and surgical time.
C: Following the lysis of the thin adhesion of the ovary the removal of Image B adhesions is completed. The normal relations between the organs have been restored (laparoscopic image).

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Fimbrioplasty (laparoscopic image).

It is performed in cases of fimbrial adhesions and when there is not total occlusion of the fallopian tube. In the case of fimbrial phimosis, lysis of the fimbrial adhesions is performed with laser CO2 and the aid of a special hook (Donnez hook) which results in the restoration of the distal portion of the fallopian tube. The patency test is performed with a special dye (methylene blue) and the pregnancy rates are high, according to the functional ability of the fallopian tube epithelium.

The term salpingostomy refers to the formation of an opening in the fallopian tubes in cases of hydrosalpinges. Salpingostomy is performed in order to unblock the fimbrial part of the fallopian tube (of the hydrosalpinx). In the past, salpingostomy was the only solution to hydrosalpinges. Nowadays, following the successful application of assisted reproduction programs, its usefulness is debatable as it offers a probability of tubal patency of up to 80% and a pregnancy rate from 0 to 25%. The chances of an ectopic pregnancy after salpingostomy may be up to 5%. As a matter of fact, there are many who support that the fallopian tubes must be removed or ligated prior to proceeding with IVF due to their negative effect on pregnancy rates.

VIDEO: Formation of an opening in the fallopian tube – salpingostomy.

Final salpingostomy result after laser laparoscopic surgery.

As far as the surgical approach of hydrosalpinges with salpingostomy, there are many (Donnez, Dubuisson, Canis, Nezhat, Manhes) that support that in certain cases selected with strict criteria, the pregnancy rates approximate these of assisted reproduction. Prognostic factors for the result are the degree of distension of the fallopian tube, the presence of folds, the presence of endotubal adhesions and the microscopic and macroscopic condition of the fallopian tube mucosa.

According to Donnez, the distension of the fallopian tubes is classified in 5 categories, with category 1 that refers to fimbrial phimosis with limited patency (he mentions 60% pregnancy rates) having the best prognosis and category 5 that refers to hydrosalpinx with thick walls and lack of folding (for which salpingectomy is recommended) having the worst prognosis.

On a technical level, mobilization of the fallopian tube and the ovary with lysis of any adhesions is initially undertaken. Following that the hydrosalpinx is opened with laser CO2, its patency is evaluated and the condition of the duct is roughly assessed. The procedure is completed with the eversion of the hydrosalpinx distal ends (cuff neostomy) with the aid of SwiftLase.

Salpingostomy
Α: Hydrosalpinx (laparoscopic image).
B,C: The hydrosalpinx is opened with the aid of special hooks and laser CO2 (laparoscopic image).
D: The opened distal ends are everted (cuff neostomy) with the aid of SwiftLase (laparoscopic image).
Ε: The final result, with methylene blue coming out freely towards the peritoneal cavity (laparoscopic image).

In literature the argument on whether to perform salpingostomy under certain criteria and or remove the hydrosalpinges prior to proceeding with IVF is noted. In addition, it is not clear whether salpingectomy has a negative effect on the haematosis of the ovaries and therefore the development of the follicles.

The removal or ligation of the fallopian tubes is better to be performed under certain criteria, as a satisfactory pregnancy rate has been observed in IVF without the surgical removal or ligation of hydrosalpinges. Some of the criteria for salpingectomy include: large distension of hydrosalpinges which is obvious in transvaginal ultrasound, hydrosalpinges with thick walls and failure of one or two consecutive IVF treatment cycles with good embryo quality (embryos with satisfactory cell number and good blastomere morphology). The transvaginal ultrasound although highly specialized has poor sensitivity to the diagnosis of hydrosalpinges. The diagnosis of hydrosalpinges is mainly made with hysterosalpingography and is confirmed with laparoscopy.

In conclusion, the selection of salpingostomy or salpingectomy in the laparoscopic approach of hydrosalpinges must be decided according to strict pre-operative peri-operative criteria. The different treatment solutions must be explained to the subfertile couple in a clear manner so as to avoid any trouble and lose precious time. Nowadays, IVF which has high pregnancy rates is the treatment of choice for hydrosalpinges, while salpingostomy should only be offered as an alternative solution to young women with hydrosalpinges.

During the last few years, ovarian cysts are treated with laparoscopic surgery with excellent post-operative results. Thorough assessment precedes in order to exclude the possibility of a malignancy with pre-operative (ultrasound, magnetic resonance imaging scanning, computerized axial tomography scanning and molecular indicators of neoplasia) and post-operative laparoscopic criteria. The management of ovarian cysts with laparoscopic surgery has given rise to many discussions and disputes, while there are always questions over the possibility of malignant neoplasia.

Para-ovarian cyst during removal with laser laparoscopic surgery.

The possibility of malignancy in ovarian cysts during reproductive age (13-25 years) is estimated around 1.5-4% for every 100,000 women. In addition, there are many that support that lysis of malignant cysts and dispersion of their contents does not affect the final survival of these patients. In contrast, the factors that play an important role are they histologic type, the degree of tumor differentiation, the presence of ascites and any possible implantations in the peritoneum or the epiploic foramen.It is common practice to administer contraceptives for three months once an ovarian cyst has been diagnosed. It the cyst does not disappear after three months, a careful ultrasound assessment is needed, along with a CA-125 level and other indicators measurements, and in some cases performing a CT or MRI scan.

The cyst was removed without rupture and has been placed inside the endoscopic sac. In this way, scattering of the contents is prevented, and the cyst is removed from the peritoneal cavity (laparoscopic image).

Ultrasound criteria correlate with the size, the location, the presence of ascites, the presences of cysts and solid areas in the same cyst, the sheer cyst or solid appearance, the thick walls, etc. Besides, the transvaginal Doppler ultrasound with colour flow imaging is a modern examination that offers significant assistance in determining blood flow in the cyst area. From the biochemical test, the C1-125 indicator is useful but has higher sensitivity and specificity for post-menopausal women.Laparoscopic criteria for benign findings (Mage G, 1987) correlate with the thickness of the wall, the vascularisation of the cyst, the colour of the fluid contents, the length of the same connection of the ovary and the appearance of the internal wall of the cyst. According to the pre-operative and peri-operative assessment of the cyst, laparoscopic surgery is performed. Special care is taken in the removal of the entire capsule (shell) of the cyst without it rupturing, as well as in the maintenance of the healthy ovarian tissue.In the case of rupturing, the cyst is thoroughly aspirated and its contents along with the fluids from washing out Pouch of Douglas are sent for cytological examination. A thorough examination of the internal of the cyst is then performed, in order to exclude any possible damage, the entire capsule of the cyst is removed and a quick biopsy is performed even when there is only suspicion of malignancy. For the removal of the cyst from the peritoneal cavity a special endoscopic pouch is used.

Types of ovarian cysts

The most common cysts in women of reproductive age are: the endometriotic (endometriomas), the dermoid and the cysts with clear content (bloody or mucoid).

Dermoid cysts

Removal of a dermoid cyst with laser laparoscopic surgery (laparoscopic image).

Dermoid cysts or mature teratomas are in general benign cysts. They comprise of a single cavity that is usually filled with puss, hair, bone tissue elements, teeth etc. These findings are usually mature tissue, while other types of tissue may also be found. Very rarely, there is the possibility of malignant cells to be found in its contents and that is why the histological examination is of great importance.

VIDEO: Dermoid cyst.

Their removal with laser laparoscopic surgery has an advantage over laparotomy as almost the entire healthy tissue remains untouched. Sometimes, the detachment of the cyst can be hard and thus great experience is required from the surgical team. The removal of the cyst from the abdomen is done with its placement in a special endoscopic pouch.

Paraovarian cysts

Paraovarian cysts develop in the mesosalpinx (the space between each fallopian tube and its neighbouring ovary) and they are embryonic remnants of the Wolf's and Gartner's ducts (structures equivalent to the spermatic duct in men). They constitute benign cysts and they should be differentiated from paratubal cysts.

Special attention is needed for paraovarian cysts in women of reproductive age in order to avoid any trauma in the fallopian tube, which is elongated and sometimes hard to distinguish on the surface of the cyst.

Laser laparoscopic surgery is the ideal solution for the removal of such cysts.

A: Left paraovarian cyst. The uterus, left ovary and oviduct are also visible.
B,C: Removal of the cyst cortex using laser CO2.
D: End of operation. All anatomical relations have been reinstated and the left oviduct remains untouched.

Paratubal cysts

Cystic degeneration of the fimbriae (laparoscopic image).

These cysts are a continuation of the fallopian tubes, they are usually found in the fimbrial part of the fallopian tube and they represent cystic degeneration of the cilia of the fimbriae and hydatid cysts of Morgani.

These cysts do not constitute an indication for surgical approach and they are only treated laparoscopically if they are found during a laparoscopy performed due to another reason.

Functional cysts of the ovaries are managed conservatively, unless complications arise, such as torsion, rupture and haemorrhage, which are treated laparoscopically. The term functional cysts of the ovaries, refers to the cysts of the follicle and the cysts of the corpus luteum.

Follicular cysts

Cysts of the follicle appear quite often during reproductive age range and are a result of Graafian follicle rupture failure in cases of unovulation. Their diameter ranges between 4-10 cm. They usually absorb on their own after 2-3 menstrual cycles or they rupture and they rarely persist. The administration of contraceptive pills or progesterone preparations may aid their disappearing. In young women of reproductive age, the contents of the cysts can be aspirated via a transvaginal, ultrasound guided paracentesis and sent for cytological examination. Ofcourse, criteria for the exclusion of any malignancy (ultrasound criteria for vascularisation with transvaginal Doppler ultrasound and indicators such as CA-125) should be taken in mind. However, generally none of these criteria can totally ensure that the cysts are functional and benign.

Corpus luteum cysts

They develop after ovulation and they represent the cystic transformation of the corpus luteum. Usually, they do not cause any symptoms or they may appear as a persistent corpus luteum and also they subside on their own.They are of unknown cause and when they are many, they are usually seen after administration of ovulation induction drugs. They are more common in women with unexplained subfertility and high FSH values on day 3 of the menstrual cycle. The diagnosis is usually made with ultrasound, hormone assessment and clinical examination. In rare instances of cyst rupture, when it is haemorrhagic, the symptoms are caused by large intra-abdominal haemorrhage and they are similar to those of ectopic pregnancy. Such conditions are mainly managed laparoscopically.

What is it and how does it develop

Endometriosis is a condition that is characterized by the development and function of ectopic endometrial tissue in an ectopic (outside of the uterine cavity) location. It is well known that the endometrial cavity is the normal location for the development and function of endometrial tissue. Endometrium is the tissue (mucosa) that covers internally the uterine cavity and is shed with blood during menstruation (menstrual bleeding).

Where is it located

Endometriosis is mainly located in the pelvis and more commonly in the ovaries, the parietal peritoneum and the retroperitoneal space (i.e. in the rectovaginal septum, the ureters and the urinary bladder), or more rarely in the serous coat of the intestine (sigmoid or iliac) and in the vermiform appendix.

Exceptionally rare endometriosis sites of origin have been located in the navel (umbilicus), in laparotomy or perineotomy scar tissue and in distal parts outside the peritoneal cavity such as in the thorax, the pericardial cavity, the kidneys, the pancreas, the skin and elsewhere.

From a point of localization in the pelvis, endometriosis can be classified as:

• peritoneal
• ovarian
• endometriosis of the rectovaginal septum

How is it diagnosed

Serious suspicions for its diagnosis arise by symptomatology (dysmenorrhoea, dyspareunia), bimanual gynaecological examination (with hard uterosacral ligaments, painful hard nodules in the Pouch of Douglas) and subfertility. In cases of ovarian endometrial cysts, transvaginal ultrasound, magnetic resonance imaging (MRI) scanning, computerized axial tomography (CAT) scanning, can usually aid in the diagnosis pre-operatively with great accuracy. The final diagnosis for endometriosis is made with laparoscopy, which is the treatment of choice: with laparoscopy, apart from confirming the condition it is possible to define exactly the extent and the stage of the disease.

Endometriosis and laser laparoscopy

In endometriosis, the endometrium (i.e. the tissue that lines the inner cavity of the uterus and is discharged with period blood) develops and functions outside the uterus (i.e. in an ectopic location). Endometriosis is the second most frequent gynecological conditions after fibroids.

It is related to infertility, pelvic pain, chocolate ovarian cysts, adhesions, dysmenorrheal (period pains) and dyspareunia (pain during intercourse). Depending on the site it is located in the pelvis, endometriosis is classified as peritoneal, ovarian (endometrioma-chocolate cysts) and endometriosis (or adenomyosis) of the rectovaginal septum.

Laser laparoscopy is the optimal method for the treatment of endometriosis. The precision of the method allows the selective removal of the damage and protects neighbouring vital organs and healthy ovarian tissue. Vaporization of peritoneal endometriosis using CO2 laser is the ideal method of treatment.

Vaporization using SwiftLase has an advantage over laparoscopic cyst removal because it allows larger reserves to remain in the ovary as it removes no healthy ovarian tissue.

For more information you may refer to our published study (Treatment of peritoneal and ovarian endometriosis by using CO2 laser with or without SwiftLase, Lainas, Petsas, Stathopoulos, Bournas, Eliadis, 4th Congress of the European Society for Gynaecological Endoscopy (ESGE) Brussels, Belgium, 6-9 Dec 1995).

Laparoscopic diagnosis of peritoneal endometriosis is usually made with the observation of typical black or blue lesions. However, there is also a significant number of atypical signs of peritoneal endometriosis that where histologically documented and described in 1986 (Donnez, Jansen, Russell). The identification of these atypical lesions increased the rates of diagnosing endometriosis from 15% in 1986 to 65% in 1988 according to the previously mentioned researchers.

A. Peritoneal endometriosis - Typical black lesion in the Pouch of Douglas (laparoscopic image).
B. Peritoneal endometriosis – Typical black lesion in the Vesicouterine Pouch (laparoscopic image).
C. Peritoneal endometriosis – Typical black lesion in the Vesicouterine Pouch (laparoscopic image).

VIDEO: Peritoneal endometriosis

The ectopic endometrial tissue behaves as the normal endometrium during menstruation, with the manifestation of small bleeding. In the peritoneum, the ectopic endometrium creates characteristic lesions that may be typical or atypical. Typical black lesions derive from bleeding of the tissue and blood encapsulation. Histologically they are made up from glands, stroma and intraluminal debris.

A. Typical black lesions amongst red lesions (laparoscopic image).
B. Combination of typical and subtle lesions (laparoscopic image).
Γ. Combination of white lesions, hyper-vascularity and peritoneal absence (laparoscopic image).

Subtle lesions

Sometimes, the subtle lesions are the only laparoscopic findings. Subtle lesions are more common and may be more active than the typical black lesions. According to the colour that they have, subtle lesions may are distinguished in red and white ones.

The red lesions include:

• red flame-like lesions, (Jansen RPS & Russell P., 1986),
• glandular excrescenses, (Jansen RPS & Russell P., 1986),
• areas of petechial peritoneum, (Donnez J. & Nisolle M., 1988),
• areas with hyper-vascularity, (Donnez J. & Nisolle M., 1988).

The white lesions include:

• white opacification, (Jansen RPS & Russell P., 1986),
• subovarian adhesions, (Jansen RPS & Russell P., 1986),
• cafè au lait (yellow-brown) peritoneal patches, (Jansen RPS & Russell P., 1986),
• circular peritoneal defects, (Chatman D.L., 1981).

The black forms are the typical black lesions. The presence of trapped menstruation is responsible for the typical black appearance.

Histological findings

Peritoneal endometriosis (atypical laparoscopic appearance): red flame-like lesions.

In the typical lesions, endometrial glands and stroma were found (which are characteristic histological findings in endometriosis) in 76% of the cases. In the subtle lesions, endometriosis was confirmed (Jansen & Russell, 1986) in 81% of the white opacifications, 81% of red flame-like lesions, 67% of glandular excrescenses, 50% of ovarian adhesions, 47% of cafè au lait (yellow-brown) peritoneal patches and 45% of peritoneal defects.

Surface red endometriosis of the ovary (laparoscopic image).

Ovarian endometriosis makes up 50-70% of all cases of endometriosis (Sampson, 1921). Surface lesions of the ovary are similar to the ones of peritoneal endometriosis. Ovarian endometriosis usually assumes a cystic form which is known as endometrioma.

Endometriomas, which are also known as chocolate cysts, usually have a diameter of 1-6 cm, although cysts of up to 25 cm diameter have been also been observed. The small bleeding of ectopic endometrium forms cystic enlargements of haemorrhagic content in the ovaries, which then turns brown or black (chocolate cysts).

Endometriotic cyst of the left ovary (typical laparoscopic image).

VIDEO: Endometriosis: Removal – sublimation.

Histological confirmation of the ovarian endometriomas is advised when functional glands and stroma are found.

Classification of chocolate cysts

Nezhat et al. (1992), categorized chocolate cysts according to their laparoscopic appearance, the contents of the cyst and the easiness of their removal from ovarian tissue. The histological findings on which this classification is based refer to the observation of endometrial glands and stroma.

The two types of chocolates cysts are:

• Type I (primary endometriomas): they are the true endometriomas and they have the same origin as peritoneal endometriosis,
• Type II (secondary endometriomas): they are cysts of the follicle or the corpus luteum and they filter out from endometriotic implants or from primary endometriomas.

Small ovarian endometrioma (laparoscopic image).

Secondary endometriomas (chocolate cysts), may be of three types: IIA, IIB, IIC and they are cysts larger than primary endometriomas (3-20 cm). Their content varies from haemorrhagic to thick chocolate-like.

Ectopic endometrial tissue can also be observed in the rectovaginal septum and this condition is called deep endometriosis or adenomyosis of the rectovaginal septum. Adenomyosis of the rectovaginal septum is also called adenomyotic disease of the retroperitoneal space (Donnez & Nisolle) and it includes the endometriosis of the urinary bladder and the ureters. The term adenomyosis refers to the ectopic development of the endometrium (of the glands and the stroma) inside the muscular wall of the uterus (myometrium).

Endometriosis of the rectovaginal septum (laparoscopic image).

Endometriosis of the rectovaginal septum is characterized by disappearance of the Pouch of Douglas and it is similar to the defect that is caused by the extensive solid adhesions of the Pouch of Douglas that vanish its lower part and join the rectum with the vagina or even with the lower part of the uterus. The adhesion of the vagina, the uterus and the intestine is caused by an adenoma of endometrial type that penetrates that cervical and uterine tissue, as well as the anterior wall of the rectum but to a different degree.

VIDEO: Endometriosis of the rectovaginal septum.

The symptoms include pelvic pain (which is the main symptom), subfertility in 25% of cases (in a total of 1125 women in a study by Donnez et al, 2001) and rectal haemorrhage during menstruation (which is exceptionally rare).

With palpation, painful nodules can be found in posterior vaginal dome and their diameter can be estimated.

The laparoscopic image is characterized by:

• complete disappearance of the Pouch of Douglas, and thus the outline of the posterior vaginal dome is not clear with the laparoscope,
• partial reduction of the Pouch of Douglas,
• no reduction at all.

Sometimes, a deep penetrative damage of the rectovaginal septum is only vaguely visible laparoscopically. Such damage has been characterized as penetrative endometriosis type III (Koninckx, 1992).

There are two different types of deep endometriosis (Donnez & Nisolle, 1997):

• the true penetrative endometriosis that is cause by the penetration of an exceptionally active peritoneal lesion in the retroperitoneal space,
• adenomyosis of the rectovaginal septum which is mainly made up of smooth muscle with an active glandular epithelium and thin stroma. This condition has been called adenomyotic disease of the retroperitoneal space (Donnez & Nisolle). It is a sever condition and it includes the endometriosis of the urinary bladder and the ureters. Besides, 35% of cases of urinary bladder endometriosis are associated with peritoneal endometriosis, while 65% is associated with retroperitoneal adenomyosis.

Treatment

The treatment of rectovaginal septum endometriosis requires considerable experience of the surgeon and his associates. Surgical correction is difficult and includes the correction of anatomical structures, the separation of anterior wall of the intestine from the posterior wall of the cervix and the uterus, and finally the removal of the adenomyosis and vaporization of any visible endometriotic damage.

• Treatment
• Laser laparoscopic surgery
• Surgical procedure
• Sublimation or removal of the cysts

Treatment

The treatment of choice for endometriosis is the combination of laser laparoscopic surgery and pharmaceutical administration. With the aid of CO2 laser and the use of SwiftLase, the sublimation of endometriotic sites of origin can be performed safely and accurately, whether these sites are small lesions of peritoneal endometriosis, extensive endometriosis or chocolate cysts. After the surgery, it is advisable to follow treatment with GnRH agonist analogues.

VIDEO: Endometriosis of the rectovaginal septum.

Surgical treatment of peritoneal, ovarian and rectovaginal septum endometriosis is usually combined with pharmaceutical administration. The aim of such treatment is to suspend the function of ectopic endometrial tissue and is usually achieved with the use of GnRH analogues (GnRHa).

Laser laparoscopic surgery

It is the ideal method of treatment for endometriosis. The accuracy of this method allows the selective distraction of the damage and it protects the neighbouring vital organs and the healthy ovarian tissue. Sublimation with SwiftLase is superior to cauterization with the use of conventional electrosurgical units (diathermies), since just with the addition of SwiftLase we can achieve a small depth of sublimation in the tissue, which is known and specified from histological studies and does not leave any traces of carbon.

SwiftLase is a laser flash-scanner that is made up of two almost parallel mirrors that rotate fast with the aid of a special motor, which results in the fast movement of the focused spot size of the CO2 laser beam. Histological studies (Donnez et al., 1994) have proven that with the use of SwiftLase and laser with a power greater than 30 W, we can achieve surface sublimation of any damage without any traces of carbon. The crater that results in a 0.1 second has a 2.5 mm diameter and a 0.2 mm depth. Fine and slow movements along the observed damage with the laparoscope have a surgical treatment result of sublimation with a final depth of 0.05-0.1 mm.

Sublimation of peritoneal endometriosis with SwiftLase (laparoscopic image).

The aim of laser laparoscopic surgery in endometriosis is the lysis of any adhesions, the restoration of the normal anatomical relations, as well as the sublimation or the ablation of all visible endometriotic sites of origin. The use of laser CO2 with the addition of SwiftLase allows the sublimation of areas of peritoneal endometriosis that are located next to vital organs (urinary bladder, intestine, large blood vessels etc.). Moreover, retroperitoneal injection of saline allows the complete sublimation of any damage with safety.

Surgical reparation is hard and it includes, separation of the anterior wall of the intestine from the posterior wall of the vagina and the uterus and the removal of the adenomyotic nodule and the sublimation of any visible endometriotic lesion.

Surgical techniques

Small site on the surface of the ovary (<1cm diameter) can be treated easily with sublimation using SwiftLase.

Sublimation of a small ovarian endometrioma (EUGONIA archive).

For ovarian endometriomas (diameter <3cm) a small opening of 5 mm length is createdusing laser CO2 on the top of the cyst, the chocolate fluid is aspirated and the interior of the cyst is washed thoroughly with saline. After washing, the inside of the cyst is examined to confirm the absence of any suspicious stems on the interior (to exclude malignancy). If there is even a small suspicion, sublimation is not performed but a biopsy is taken.

If the interior is free of damages, sublimation at high power is performed. In this way only the ectopic endometriotic epithelium is destroyed, maintaining the underlying healthy ovarian tissue. The ovaries are then thoroughly washed.

Sublimation or removal of the cysts

Sublimation of ovarian endometrioma. The cyst has been incised and is sublimated with SwiftLase. (laparoscopic image).

The surgical practice of sublimation versus excision is the correct treatment choice, especially for endometriomas smaller than 3 cm. According to the classification of Nezhat (1995), they are regarded as true endometriomas, which are impossible to remove, because there is not an anatomical or histological separation plane of the endometrioma from the underlying ovarian tissue. According to the hypothesis of Hugheston (1957), ovarian endometriomas are the result of engulfment of surface fragments of endometriotic tissue in the ovary. Therefore, in the attempt of their removal based on an artificial separation plane between endometrioma and ovarian tissue, some ovarian cortex (containing follicles) is also removed. Sublimation of endometriotic cysts using Swiftlase has advantages over laparoscopic cyst removal, because after treatment ovarian reserve is maintained.

Sublimation of ovarian endometrioma. Detail of sublimation (laparoscopic image).

For endometriomas larger than 3 cm, after their opening, washing and examination to exclude any suspicious damage, follows careful peeling of the cyst from the ovarian tissue. If peeling is easy, the cyst is removed entirely. If there is strong adhesion then Swiftlase is used. In case that some sites of the wall are attached to the ovarian tissue, the cyst is partially removed and the remaining is sublmimated using Swiftlase.