​

Surgical Management of Endometriosis

A substantial component of my clinical practice is dedicated to the comprehensive surgical management of endometriosis. Endometriosis is a chronic, heterogeneous condition characterized by variable disease distribution, symptom severity, and impact on quality of life and fertility. As such, management requires an individualized, evidence-based approach, with surgery forming a key component of care for appropriately selected patients.

 

Role of Surgery in Endometriosis Care

While medical therapy plays an important role in symptom suppression, surgery remains the definitive modality for diagnosis and anatomical disease eradication. Surgical intervention is most often considered in patients with persistent symptoms despite optimized medical therapy, intolerance or contraindications to hormonal treatment, suspected deep infiltrating disease, or in those where fertility preservation or restoration is a priority.

 

Laparoscopy is the gold standard surgical approach, allowing for accurate disease mapping, histologic confirmation, and definitive treatment within a minimally invasive framework.

 

Surgical Techniques and Disease-Specific Approaches

Excision of EndometriosisContemporary endometriosis surgery prioritizes complete excision of disease, rather than ablation, wherever technically feasible.

 

Excision allows for:

•Removal of endometriotic implants at their depth of infiltration

•Histopathologic confirmation

•Improved long-term pain control and reduced recurrence rates

 

Disease may involve the peritoneum, ovaries, uterosacral ligaments, rectovaginal septum, bladder, ureters, or bowel.

 

Surgical complexity is dictated by disease location and depth, and procedures are tailored accordingly to ensure maximal symptom relief while preserving normal anatomy and organ function.

 

Management of Deep Infiltrating Endometriosis (DIE)

Deep infiltrating endometriosis may affect pelvic nerves, the urinary tract, or the gastrointestinal system and often presents with complex pain syndromes or organ-specific symptoms.

 

Surgical management may include:

•Ureterolysis

•Bladder dissection

•Rectovaginal or bowel shaving

•Segmental bowel resection in selected cases

Ovarian Endometriomas

Surgical treatment of ovarian endometriomas must balance effective disease removal with preservation of ovarian reserve, particularly in patients with reproductive goals. When surgery is indicated, cystectomy using tissue-sparing techniques is generally preferred, with careful attention to minimizing thermal and mechanical injury to normal ovarian tissue.

 

Hysterectomy in Endometriosis

In selected patients who have completed childbearing and have refractory symptoms, hysterectomy may be considered as part of a broader surgical strategy. Importantly, hysterectomy alone does not treat extra-uterine endometriosis; therefore, complete excision of endometriotic disease remains essential, irrespective of whether the uterus is removed.

 

Decisions regarding ovarian conservation are individualized based on age, fertility wishes, symptomatology, and recurrence risk.

 

Clinical Treatment Pathways

Patient Assessment and Surgical Planning

​

Preoperative evaluation includes:

•Detailed symptom assessment, including pain phenotype and organ-specific symptoms

•Review of prior medical and surgical treatments

•Targeted imaging (ultrasound and/or MRI) for suspected deep disease

•Consideration of fertility goals and long-term management planning

 

Integration With Medical Therapy

Surgery is integrated into a longitudinal care model. Post-operative hormonal suppression is frequently recommended to reduce recurrence risk, particularly in patients not actively pursuing pregnancy.

 

Adjunctive therapies, including pelvic floor physiotherapy and pain-focused interventions, are incorporated as needed.

 

Philosophy and Outcomes

Endometriosis surgery is most effective when:

•Guided by realistic expectations and shared decision-making

•Performed by surgeons with advanced training in minimally invasive surgery

•Embedded within a multidisciplinary care framework

 

The primary objectives of surgical management are durable symptom relief, restoration of pelvic anatomy, preservation of organ function, and improvement in overall quality of life.