Surgical Treatment Options

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The information on my platforms is educational information only and not medical advice. Always check with your qualified medical professional before making any changes to your treatment plan. Keep in mind that while I strive to share evidenced-based information on endometriosis, this doesn’t always mean that my information is accurate or complete. See my full disclaimer here.

Surgery is usually done via laparoscopy

Laparoscopy is less invasive than laparotomy, typically with less surgical complications and a faster recovery time. 

Laparoscopy can be via robotic surgery or a standard laparoscopy – both techniques can potentially give the patient a good outcome with low complication rates. 

There are 2 different surgical techniques when it comes to endometriosis: ablation and excision

• Ablation surgery is the superficial burning of endometriosis on the surface level.
• Excision surgery is the removal of endometriosis lesions at the root.

Patient outcomes

Studies using quality-of-life comparisons and questionnaires before and after surgery have shown with excision, many* people find that their endometriosis pain significantly reduces and their quality of life improves. With ablation however, many find their endometriosis pain returns within just months after surgery. The Center for Endometriosis Care has done an amazing job listing out studies which support the use of excision on their page Excision of Endometriosis. 

*It’s important to know that there are no guarantees, and not all patients have pain/symptom reduction, or sustained reduction, from excision.

Recurrence/persistence rates

Recurrence means disease coming back after surgical removal. Persistence means disease remaining because it wasn’t removed during the surgery. We don’t know the exact rates of disease recurrence or persistence, because they vary in the medical literature depending on multiple factors. See my page on Endometriosis Recurrence. 

However, we do know that:

• recurrence/persistence rates are much lower for excision than for ablation
• the excision surgeon’s skill plays an important (although not the only) role in recurrence/persistence

Recurrence and persistence are usually talked about together because it can be hard to know if the disease was removed and recurred, or if it was left behind and persisted. However, when it comes to ablation, it’s typically disease persistence since the endometriosis wasn’t truly removed in the first place since it was only superficially burned. Because the disease isn’t removed, many patients end up having multiple ablation surgeries year after year without seeing any long-term relief to their pain.

What are the benefits of excision over ablation?

Better outcomes

• Lower recurrence/persistence rates and better long term outcomes with excision (as mentioned above).
• Some people find that after an ablation, they have more pain than before. The burning of ablation surgery can lead to more damage by leaving behind carbon and thermal damage, which can stimulate a foreign body giant cell reaction and become its own cause of pain.

Pathology confirmation of endometriosis

• Excision allows for the removed tissue to be sent to pathology for confirmation that it’s endometriosis, while due to the burning with ablation (and not the cutting out of tissue like with excision), the tissue is often unable to be sent to pathology for confirmation. In some instances with ablation, carbon or scarring from previous treatments is being treated rather than endometriosis.

More complete removal of endometriosis

• Due to the heat generated with ablation surgery, it usually cannot treat endometriosis on delicate tissues such as the bladder or intestines. With excision, the excision surgeon will often work with a multidisciplinary team, such as a general/bowel/thoracic/etc surgeon, to excise endometriosis from all organs where endometriosis is present.
• With ablation, the surgeon isn’t able to see how deep into the tissue the endometriosis is. Even most superficial endometriosis is deeper into the peritoneal surface than 2 mm, which is about the depth that ablation can burn off. Because of this, ablation can bury endometriosis under scar tissue. This can cause more pain, and make future excision surgeries more difficult.

Some surgeons believe that ablation for endometriosis should be banned. Not only does ablation have poorer outcomes, but having had the tissue burned makes future excision surgeries more difficult and may affect the outcome.

Excision and ablation are very different and one shouldn’t talk about “endometriosis surgery” as if they were the same

This is a huge problem in endometriosis care: excision and ablation are often lumped together in studies, online articles, and even endometriosis guidelines.

USA guidelines: The ACOG Practice Bulletin 114 on endometriosis talks about “surgical therapy” and “laparoscopy” but gives no recommendation on excision vs ablation for the surgical treatment of endometriosis pain. The ACOG Committee Opinion for Dysmenorrhea and Endometriosis in the Adolescent also talks about conservative surgical therapy with no recommendation on excision vs ablation: “lesions should be destroyed, ablated, or excised”.

We should be distinguishing the type of surgery when we talk about surgery outcomes, risks, recurrence/persistence rates, etc. Not doing so keeps excision inaccessible because it holds us back from making endometriosis care into a much-needed subspeciality. It prevents surgeons in the USA from being properly reimbursed for doing excision, which is currently paid the same as a much shorter and less complex ablation surgery. This also affects surgical training. Why train in excision when you can just do ablation, a much easier and less complex surgery?! Endometriosis surgery is endometriosis surgery, right? Wrong!

All excision isn’t equal either because excision depends on the surgeon’s skills to recognize and remove endometriosis

We need the medical community to recognize that not all surgeons are equal and skill levels vary drastically, which influences patients’ outcomes and the data we have on excision surgery. It’s important to distinguish between the outcomes expert excision surgeons have and less skilled excision surgeons have, so that we can try to train more surgeons and bring them all up to an expert level.

The medical community needs to recognize endometriosis as a subspecialty, to help standardize the training as well as the title “endometriosis specialist” which currently means nothing. 

Most people worldwide can’t access expert excision

Excision surgery is a privilege most people can’t access. And even for those who can, due to the different skill levels among surgeons, some end up having an incomplete excision, which can lead to continued pain and symptoms.

For those who want to have excision but can’t access it, I truly hope it will become accessible to you in the future. And for those who did access it but didn’t have the outcome they’d hoped for, I’m sorry you’re in that position and I truly hope you can find symptom relief.

You need to make the best choice for you

There are many patients who regret having done an ablation surgery. While it’s up to you as an individual, many people find it’s better to wait to operate until they find a skilled excision surgeon, rather than do ablation. The problem is that many people are not being fully informed by their doctors of the risks or the limitations of treatments. When we have all the information, we can better choose the treatment option that is right for us – one that is affordable, accessible, and makes the most sense to us after having evaluated the risks, benefits, and our personal situation.

See my page 5 Important Facts About Excision.