The aim of this study was to evaluate the laparoscopic approach to benign adnexal masses in 211 premenopausal patients selected with strict preoperative clinical and ultrasound diagnosed criteria. Most patients were successfully managed with operative laparoscopy (98.2%). Four patients underwent laparotomy (1.8%). The rate of unexpected adnexal malignancy was 0.48%. We believe that operative laparoscopy is a safe and effective procedure for treating most benign adnexal masses in premenopausal women. To reduce the possibility of encountering an unexpected malignancy when approaching an adnexal cyst by laparoscopy, appropriate preoperative selection of patient candidates for laparoscopic treatment is mandatory. If an unexpected malignancy arises during laparoscopy, a team with specific oncologic training should be available for a possible immediate staging laparotomy in order not to affect the patient's prognosis.