To the Editor:
We read with interest the recent review conducted by Jadoul et al. (1) on the surgical treatment of ovarian endometriomas. The authors stress, as we do, that laparoscopic cystectomy for ovarian endometriomas may be difficult, and that a meticulous surgical technique should be used. The stripping technique, similar to that used for other benign cysts, cannot be used for this situation as it may induce severe bleeding and damage to the ovary (2, 3, 4). As we published before, the authors suggest that whenever the plane is adequately exposed, the surgeon may identify “arrows” on the surface of the cyst wall. These “arrows” help the surgeon to identify the correct cleavage plane. Indeed, a precise cut on the top of the arrow will present a safe and bloodless plane close to the cyst wall and away from the normal ovarian tissue, which should be preserved as much as possible.
However, we found that the “arrows” shown by the authors of this paper are not well representative of this very important laparoscopic sign. Looking at their pictures, readers may understand that the “arrows” are visible on the remaining ovarian stroma, whereas we emphasized several times that the “arrows” are visible on the surface of the cyst (4). Some examples of what we consider good surgical “arrows,” which should be followed to avoid unnecessary ovarian damage, are presented in Figure 1.
Finally, we would like to emphasize that this very accurate surgical sign is visible only when exposure and hemostasis are adequate.
Department of Gynecologic Surgery
CHU de Clermont-Ferrand, Polyclinique de l’Hôtel Dieu
1. Jadoul P, Kitajima M, Donnez O, Squifflet J, Donnez J. Surgical treatment of ovarian endometriomas: state of the art? Fertil Steril 2012;98:556-63.
2. Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum Reprod 2001;16:2583-6.
3. Canis M, Mage G, Wattiez A, Pouly JL, Bruhat MA. The ovarian endometrioma: why is it so poorly managed? Laparoscopic treatment of large ovarian endometrioma: why such a long learning curve? Hum Reprod 2003;18:5-7.
4. Kondo W, Bourdel N, Zomer MT, Slim K, Rabischong B, Pouly JL, et al. Laparoscopic cystectomy for ovarian endometrioma: a simple stripping technique should not be used. J Endometriosis 2011;3:125-34.
Figure 1. In all examples C means cyst wall and O means ovarian tissue. The surgeon should cut the arrows visible on the cyst wall (green arrows), not those more rarely identified on the normal ovarian tissue (red arrows).
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.11.026
The authors declined to reply to this letter.