Laparoscopic Excision of Endometrioma

Endometriosis can have a significant impact on the sufferer, the gynecologist and the health care system. For the sufferer, quality of life may be significantly decreased.24 For the gynecologist it constitutes a considerable workload, accounting for 10–15% of new referrals.24 For the surgeon, the diagnosis and treatment of endometriosis accounts for 25–35% of laparoscopies and 10–15% of hysterectomies each year.25 Finally for the health care system, endometriosis imposes considerable costs; direct costs of surgical therapy are estimated at US$5805 and for medical treatments US$2418.26 The indirect costs of time away from employment, the burden of pain and its impact on quality of life are also recognized. Surgical treatment of endometriosis may be effective in relieving dysmenorrhea, dyspareunia, nonmenstrual pelvic pain and dyschesia.24,27 It is most common in the pelvic cavity, including the ovaries, the uterosacral ligaments, and pouch of Douglas. Common symptoms include dysmenorrhea, dyspareunia, non-cyclic pelvic pain, and subfertility. The clinical presentation is variable, with some women experiencing several severe symptoms and others having no symptoms at all. The prevalence in women without symptoms is 2-50%, depending on the diagnostic criteria used and the populations studied. The incidence is 40-60% in women with dysmenorrhea and 20-30% in women with subfertility.1-3 The severity of symptoms and the probability of diagnosis increase with age.4 The most common age of diagnosis is reported as around 40, although this figure came from a study in a cohort of women attending a family planning clinic.5 Symptoms and laparoscopic appearance do not always correlate. The American Society for Reproductive Medicine has published a classification of severity of endometriosis at laparoscopy. Several factors are thought to be involved in the development of endometriosis. Retrograde menstruation remains the dominant theory for the development of pelvic endometriosis, though as this is almost universal it is unlikely to be the sole explanation.7-9 The quantity and quality of endometrial cells, failure of immunological mechanisms, angiogenesis, and the production of antibodies against endometrial cells may also have a role.10,11 Embryonic cells may give rise to deposits in distant sites such as the umbilicus, the pleural cavity, and even the brain.8,9 Risk factors generally relate to exposure to menstruation: early menarche and late menopause increase the risk whereas the use of oral contraceptives reduces.5