Endometriosis Excision Surgery: What Happens and Recovery

Excision surgery is the gold standard for both diagnosing and treating endometriosis. Excision surgery involves cutting out and removing endometriosis lesions and their surrounding tissue. However, access to endometriosis excision specialists is limited, expensive, and frequently not covered by insurance.

In this article, learn more about excision surgery and its recovery process.

Excision vs. Ablation Surgeries for Endometriosis

Excision and ablation are two different methods for endometriosis surgery. Ablation is more common than excision because excision may not always be possible due to the location and extent of the endometriotic lesions. Excision surgery may also be more high-risk and more difficult to perform.

• Excision: Endometriosis lesions are cut out, removed, and the tissue is sent to a pathologist to confirm it is endometriosis.
• Ablation: The endometriotic lesions or tissue is burned to kill the diseased tissue and prevent it from growing; this doesn't allow for a biopsy or tissue confirmation by a pathologist.

Both surgical methods are minimally invasive and can be performed laparoscopically, in which only a few small incisions are made.

One systematic review and meta-analysis found that one-year post-surgery, people with endometriosis who had excision surgery had significantly improved pain during menstrual periods, painful bowel movements, and chronic pelvic pain compared to those who had ablation surgery.

Robotic-Assisted Technology 

Robotic-assisted technology, including the da Vinci robot system, is a surgical tool. With the da Vinci robot, your surgeon will sit at a console and guide tiny wristed instruments to perform the surgery. Some excision surgeons report that this system gives them better control or is less demanding on their bodies during long surgeries.

Other surgical tools surgeons use to perform excision surgery include lasers, LigaSure, and harmonic scalpels.

What Happens During Excision Surgery 

On the day of your endometriosis excision surgery, your surgical team will administer anesthesia so that you fall asleep and feel no pain during the procedure. Once asleep, they will begin surgery:

1. Your surgeon will make tiny incisions into your abdomen and pelvis (one of these is usually in your belly button). The number and location of incisions will depend on where your suspected endometriosis is and your surgeon's methods.
2. Your surgeon will insert the surgical tools into these incisions, including a laparoscope (a tube with a video camera on the end). They will use the camera to thoroughly investigate your organs, peritoneum (tissue lining the abdominal wall and pelvic area), and other places endometriosis may be found. They will take photos of anything they find.
3. Once all areas of endometriosis are noted, your surgeon will begin cutting out the diseased areas and a small area of surrounding healthy tissue. The technique will vary depending on what surgical tools they use.
4. Once all endometriosis lesions are removed, your surgeon may retake photos. They will remove any surgical tools and close your incisions.

Potential Risks 

As with any surgery, there are potential risks and complications. Some of these include:

• Drop in hemoglobin (the molecule that transports oxygen in red blood cells)
• Urinary retention (inability to pee)
• Cystitis (bladder inflammation)
• Abdominal wall hematoma (pooling of blood)
• Stoma placement (a surgically made hole that allows waste to leave the body)
• Adhesion (scar tissue) formation
• Bowel, bladder, or ureteral injury
• Infection
  

With endometriosis excision surgery, there is also the risk of losing an organ (such as your appendix).

Most complications, however, are minor or short-term, and re-operation due to severe complications is only required in less than 1% of cases.

Before your excision surgery, your surgeon should inform you of all possible risks and complications.

Finding a Specialist 

Unfortunately, there are a limited number of endometriosis excision specialists worldwide, partly due to the extensive training and experience required. Finding a specialist can be challenging and may require traveling to another city, state, or country.

When looking for an endometriosis excision specialist, you may want to vet them with questions. Nancy's Nook is a well-known endometriosis advocacy group and has lists of recommended questions for potential surgeons. Some of these questions include:

• Do you use excision or ablation surgical methods? Why?
• How many endometriosis surgeries do you perform per week? Per month? In your career?
• Will you involve any other surgeons or specialists?
• Do you ever prescribe suppressive medications before or after surgery?
• What are possible complications? What is your complication rate?

Cost

Endometriosis is often an expensive condition and one that can impact productivity (i.e., it may prevent you from working). For example, one study found that, in the United States, yearly direct costs of endometriosis (including surgery and medication) were $12,118 per person, while indirect expenses (loss of income) were $15,737 per person.

High cost is a significant barrier to endometriosis excision surgery. The lack of specialists may necessitate travel and other expenses. Many excision surgeons in the United States are also not in-network with insurance; they may still accept insurance out-of-network benefits, but this is usually reimbursed at a lower rate.

The exact cost of excision surgery will depend on individual factors such as:

• Whether or not you have medical insurance
• Your insurance plan, including deductibles, out-of-pocket maximums, and in-network providers
• Travel
• Pre-surgery procedures, such as magnetic resonance imaging (MRI) or ultrasound

Talk to your insurance company and your surgeon's office about expected costs before surgery. You may want to develop a savings plan for future surgery or change your insurance plan. For people who are uninsured or underinsured, some excision specialists may also offer payment plans or connect you with grants or donated surgeries.

Financial Wellness With Endometriosis 

Your financial wellness can impact your mental and physical wellness and quality of life. Excision surgery can be costly and may not be worth going into significant debt.

Alternatively, natural treatment methods for endometriosis—such as acupuncture, special diets, chiropractor visits, or supplements and herbs—can also be expensive and do not have evidence to support their long-term use. As your endometriosis progresses, they may be more expensive than a one-time surgery.

It may be helpful to view the expense of excision surgery as a form of investment in your future; with reduced endometriosis symptoms, you may be more financially productive after surgery and get a return on your investment.

In contrast, you may decide that you have other financial needs and priorities. Talking to your surgeon, loved ones, and even a therapist or financial advisor may help bring clarity to your situation.

Preparing for Excision Surgery

Before or at your pre-operative appointment, your surgeon should provide information on preparing for excision surgery. Exact recommendations will vary, and you should always listen to your surgeon's advice.

Hygiene

Proper hygiene will help prevent infection. Your surgeon may recommend showering with Dial or another unscented soap the night or morning before your surgery. They may also advise not shaving for several days before surgery.

Diet

Surgeons may recommend simple meals or avoiding spicy foods, nuts, or inflammatory foods before surgery.

They will also have recommendations regarding your food and fluid intake for the 24 to 48 hours immediately preceding surgery. This usually includes only consuming liquids for a certain period before the operation. You should confirm this timeline and what liquids are allowed (i.e., water, electrolytes, bone broth).

You will have to completely stop all fluid intake as surgery nears. Confirm this time with your surgeon's office.

Bowel Prep

Some endometriosis excision surgeons recomend a bowel prep (evacuating stool from some or all of your bowels) through an oral solution or an enema. Confirm this at your pre-operative appointment.

Recovery 

Recovery from endometriosis excision surgery depends on the individual. Some people may go home the same day as surgery, while others may require an overnight or extended hospital stay.

Your surgeon may also prescribe pain, anti-nausea, and/or stool softeners during your immediate recovery. They will also advise you when to use ice packs or heating pads. Abdominal binders may provide some relief; discuss this with your surgeon.

You may have difficulty sitting, bending, lifting, reaching, standing, and walking for days or weeks after surgery. Your surgeon should provide you with precautions, such as not lifting a certain amount of weight. Assistive devices, such as bed rails, canes, walkers, shower chairs, and reachers, can also improve your quality of life and independence after surgery.

Ongoing Endometriosis Management 

Excision surgery is the gold standard for endometriosis treatment but is not a cure. Many people require ongoing endometriosis management post-surgery. This may include follow-up appointments with your surgeon, visits with related specialists, a medication plan, and more.

Once the endometriosis is removed, many people still experience pelvic floor dysfunction and related symptoms from years of chronic pain and anatomical distortion. Excision surgery can also significantly reduce your core strength. For these reasons, pelvic floor physical therapy may be particularly beneficial once you've recovered from surgery.

Repeat Surgeries for Endometriosis 

Repeated surgery for endometriosis is, unfortunately, quite common. However, it's not because endometriosis grows back; rather, it was not entirely removed during the initial surgery. This is usually due to incomplete ablation surgery, less-experienced surgeons not identifying every spot of endometriosis, or microscopic implants of endometriosis.

Generally, endometriosis recurrence and repeated surgery are much less common with excision surgery than with ablation. One systematic review found that lack of complete surgical excision was a risk factor for recurring deep infiltrating endometriosis.

Summary

Excision surgery is when diseased tissue is entirely cut out and removed. It is the gold standard for diagnosing and treating endometriosis. However, there are limited excision specialists worldwide and accessing them can be expensive and challenging.

A Word From Verywell

Excision surgery can provide immense relief for many people with endometriosis. However, access to excision is expensive and inequitable. If you are struggling to access excision surgery while also managing your endometriosis symptoms, you are not alone. Take things day by day, make notes or journal your plans, talk to loved ones, and consider mental health support throughout the process.