Surgical Approach in a Giant Ovarian Endometrioma

Study Objective Report surgical approach in a difficult case of Giant Ovarian Endometrioma. Design Case report with imaging exams and description of the surgical approach, with narrated surgical video. Setting The prevalence of endometrioma is unknown, but it is expected to affect around 17-44% of women with endometriosis. The surgical management is recommended in cases as the large endometriomas. Usually, the endometrioma is adhered to the surrounding structure, therefore it is fundamental the surgeon's anatomic landmark knowledge and their experience in deep endometriosis surgery. Patients or Participants Female, 40 years old with previous nephrectomy and a giant ovarian endometrioma associated with deep endometriosis. Interventions Patient was submitted to laparoscopic surgery. A giant ovarian endometrioma occupied all the pelvis. The first step was to drain it, to make it possible to view the pelvis. Adhesiolysis was performed followed by left oophorectomy. It was primordial to dissect and visualize her only ureter. Her ureter was enlarged due to its adherence with a paracervical endometriosis nodule. After the ureterolysis and endometriosis nodule removal, there was no sign of ureter dilatation anymore. To perform a complete treatment for deep endometriosis, segmental rectosigmoidectomy and appendicectomy were done. Measurements and Main Results The patient was stable after the procedure, with hospital discharge on the 5th day after surgery. In the follow-up, the diet was slowly re-introduced, with good response. The pathology reports showed endometriosis in all specimens. The renal labs remained normal. Conclusion Giant ovarian endometrioma cases are challenging due to its requirement of surgical treatment. The imaging exams as magnetic resonance and ultrasound would give the surgeon a clue, but the final aspect of the pelvis is only known during the surgery. Therefore, it is very relevant to start the procedure with a strategy in mind.