A new technique for laparoscopic management of ovarian endometriosis.

"Surgicel"-treated endometriomas during laparoscopy show low recurrence rate.

Key Points

Highlights:

• A topical absorbable agent, "Surgicel (oxidized regenerated cellulose)", used for homeostasis during the laparoscopic cystectomy or drainage of endometrioma, seems to be effective for preventing recurrences.

Importance:

The better pregnancy outcomes, the inevitable removal of unaffected ovarian tissue during laparoscopic approaches of ovarian cystectomy. 

What's done here:

• The authors planned a randomized controlled study to evaluate the effect of the "Surgicel" application during laparoscopic procedures to prevent recurrences of ovarian endometriosis.

Key results:

• "Surgicel" treated group has a statistically significantly low hazardous recurrence, compared to untreated groups. 
• The lowest hazard was obtained in the laparoscopic cystectomy with "Surgicel" applied group when compared to the rest of the other study groups. 
• Cystic drainage with "Surgicel" group showed significantly lower hazard when compared to the drainage group without "Surgicel".
• Decreased AMH levels that indicate the failure of ovaries are significantly less in ovarian drainage with "Surgicel" application group.

Limitations:

• 24 months follow-up period of this research may not be sufficient to evaluate the recurrence of endometriomas.
• At the end of the follow-up period, only 10 of 17 women who got pregnant spontaneously were within the Surgicel group that could confuse the success of the procedure.

Lay Summary

To cause a minimal hazardous effect on ovarian reserve during laparoscopic surgery of endometriomas is always a great concern for clinicians.

Shaltout et al. from Cairo University, Egypt, examined the effect of "Surgicel" on preventing the recurrence of endometriomas and recently published their results in the "Journal of Ovarian Research".

Surgicel, an oxidized regenerated cellulose compound, acts as a physical barrier that stimulates platelet aggregation and clotting, while it's acidic nature helps to create vasoconstriction at the application area to cause denaturation of the blood proteins by forming an artificial gel-like clot.

Using these beneficial effects of "Surgicel" on tissues, authors planned a randomized controlled study on 200 endometriotic women who are candidates of a laparoscopic surgery due to their ovarian endometriomas; either by drainage or cyst wall excision, from October 2016 to January 2019.

Randomization performed by creating four groups; namely drainage, cystectomy, drainage with "Surgicel", and cystectomy with "Surgicel" and appropriate statistical significance tests were used to assess the results.

Surgeons simply drained all of the patient's endometriomas inside ovaries by using aspiration technique and either washed the cavity by saline solution or remove the cyst wall. Additionally, for "Surgicel" groups, they ultimately add this oxidized regenerated cellulose compound inside the cleaned cyst cavity or remaining ovary bodies. After their operation, patients did not take any hormonal therapy and followed-up for recurrences along a 2-years period.

To assess the ovarian reserve, they measured AMH levels of patients at the 6th month of operation, and they evaluated the presence of endometriomas more than 1 cm during the follow-up by ultrasonographic examination, for recurrence decision.

The authors found out that "Surgicel"-treated groups showed lower recurrence rates when compared to all other untreated groups. The significant drop of AMH levels after 6 months showed the negative impact of surgery on ovarian reserves for all groups, but the group with "Surgicel" application after the drainage showed the lowest drop on AMH levels compared to others.

Consequently, this prospective study shows that the surgeries applied for endometriomas as cystectomy or drainage of the cyst content either covering with or without Surgicel still carries the risk of recurrence in women with endometriosis and discussable for their pregnancy outcomes.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31325962