title: Ten Principles for Safe Surgical Treatment of Ovarian Endometriosis.
abstract: To show a step-by-step laparoscopic approach for excision of an ovarian endometrioma following surgical principles for safety and maximal preservation of ovarian function.
  
  
  
  Video. Medical management of ovarian endometriomas is not recommended. Operative laparoscopy is the treatment of choice. Although considered a simple procedure, ovarian cystectomy requires a precise and correct technique in order to preserve ovarian function.
  
  
  
  A private hospital.
  
  
  
  An asymptomatic, 27-year-old woman with ultrasound imaging suggesting a 6.2 × 5.4 cm left endometrioma. Additional findings of endometriotic implants were noted in the posterior aspect of the left broad ligament, retrocervical region, Douglas pouch, and left round ligament.
  
  
  
  After trocar insertion, standard inspection of the pelvic cavity with identification of endometriosis lesions and adhesions was performed. The endometrioma was drained with direct trocar puncture to avoid spillage of the endometriotic contents. Cyst aspiration and saline cleaning were executed. After drainage, a cold cut was performed at the puncture site for better identification of the cyst capsule. Through gentle traction and countertraction, the capsule was peeled from the ovarian cortex, preserving as much ovarian tissue as possible followed by careful hemostasis with a bipolar instrument. The ovary is fixed, anatomy re-established, and concomitant pelvic endometriosis resected. We aim for complete surgical excision in order to avoid leaving disease behind. The ovarian edges were reapproximated using simple interrupted stitches.
  
  
  
  The total procedure time was 40 minutes.
  
  
  
  Laparoscopic endometrioma stripping offers an effective option for ovarian endometriosis treatment, reducing recurrence and being reproducible by gynecologic surgeons after proper training.
authors.affiliation: Department of Obstetrics and Gynecology, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Manuel Antonio
authors.initials: MA
authors.lastname: López de la Torre
authors.affiliation: Santo Amaro Medical School-Sao Paulo/SP, Saõ Paulo, Brazil.
authors.forename: Henrique M
authors.initials: HM
authors.lastname: Abrao
authors.affiliation: Department of Obstetrics and Gynecology, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Luiz F
authors.initials: LF
authors.lastname: Fernandes
authors.affiliation: Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland OH.
authors.forename: Rosanne M
authors.initials: RM
authors.lastname: Kho
authors.affiliation: Department of Obstetrics and Gynecology, University of São Paulo Medical School, São Paulo, Brazil. Electronic address: msabrao@mac.com.
authors.forename: Mauricio S
authors.initials: MS
authors.lastname: Abrao
mesh_terms: D000291:Adnexal Diseases / Q000150:complications / Q000601:surgery; D000328:Adult; D004312:Douglas' Pouch / Q000473:pathology / Q000601:surgery; D004322:Drainage; D004715:Endometriosis / Q000150:complications / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D010049:Ovarian Diseases / Q000150:complications / Q000601:surgery*; D010052:Ovariectomy / Q000379:methods* / Q000592:standards; D010053:Ovary / Q000601:surgery; D010532:Peritoneal Diseases / Q000150:complications / Q000601:surgery; D000267:Tissue Adhesions / Q000601:surgery
keywords: Deep endometriosis; Endometria stripping; Gynecology surgeon; Laparoscopy; Ovarian endometriosis