Why is Surgical Excision Only Practiced by Select Surgeons?

Dr. Cook performing excision surgery
Advanced excision surgery requires knowledge, skill and dedication.

Surgical excision of endometriosis is arguably the gold standard in the treatment of this disease. Other techniques have been found to be ineffective in completely eradicating endometriosis, resulting in disease persistence and recurrence of symptoms despite surgery.

An important question is why aren’t more gynecologic surgeons adopting excision as their technique of choice in the treatment of endometriosis?

The answer is three-fold: There is a lack of knowledge about the effective treatment of this disease, excision requires superior laparoscopic skill that many surgeons simply lack, and dedicating ones career to perfecting the techniques required to perform complete excision places a considerable financial burden on the surgeon.


The choice of technique used by a surgeon to treat endometriosis reflects his or her knowledge about the disease. A surgeon who uses wide excisional techniques appreciates that complete removal of the disease is both necessary and attainable and that results are superior with this approach. Many surgeons approach surgery with a degree of defeatism. They expect the disease to “always come back” and believe that complete removal of the disease is futile and impossible. Their beliefs are reinforced by the results they see in their own patients following incomplete removal of the disease – the disease persists and the pain invariably recurs and the patient enters a cycle of ineffective surgical and medical therapies, with both doctor and patient feeling increasingly helpless and frustrated. Surgeons who have developed the ability to excise the disease, however, have found that many if not most of their patients do well after a single surgery without the need for hormone suppression or repeated surgery. Provided excision is wide enough, in most cases the disease and its symptoms do not recur following excision surgery.

It takes considerable skill to excise the disease widely and deeply enough from any area within the pelvic cavity. The pelvis contains multiple organs and many delicate and vital structures. While in mild cases the disease is limited to the peritoneum, the thin layer of tissue that cloaks these underlying structures, and so can be removed readily, in cases of more invasive disease, the surgeon is required to operate on or close to many different structures, such as the ovaries, the bladder, the bowel, the ureters, the diaphragm, and the major blood vessels, pelvic nerves and ligaments. As you can imagine, it takes considerable training, experience and skill to acquire the ability to operate safely in all of these areas. In severe cases of disease the pelvic structures are distorted by dense adhesions. Adhesions can make it hard for the surgeon to orientate within the pelvis and before removing the disease the scar tissue must first be carefully dissected (separated) to reveal the underlying structures without damaging them in the process. Take the example of an ovary that is fused by scar tissue to the adjacent pelvic sidewall. A ureter runs just under this area of tissue. The surgeon has to carefully detach the ovary from the adjacent tissues without causing unnecessary loss of ovarian function and without damaging the nearby ureter. It is like trying to remove a stamp from an envelop without damaging the stamp… or the envelope!

Performing endometriosis excision surgery can be both physically and mentally demanding; surgery can take many hours to complete and requires the utmost concentration on the part of the surgeon. It takes years of experience and hundreds of surgical cases to develop the necessary skill-set to become competent and accomplished in this technique. It is generally accepted that endometriosis excision surgery represents the most challenging surgery within gynecology (more complex than oncologic surgery) and in complex cases it represents some of the most challenging surgery performed within any surgical sub-specialty.

Excision surgery carries a considerable financial burden for the practitioner due to the need for extensive training and experience with poor reimbursement. Insurance companies do not acknowledge the time and skill required to perform this specialized form of surgery. Reimbursement of excision is exactly the same as reimbursement for standard endometriosis surgery. An OB/GYN who performs superficial treatment of endometriosis during a 30-minute procedure will receive the same reimbursement as a specialist who spends 5 hours painstakingly excising all areas of disease while preserving the patient’s organs. This explains why the vast majority of endometriosis excision specialists are forced to work privately in order for their practices to be sustainable while offering patients the level of care and attention they need and deserve, which in turn can make it difficult for some patients to access the surgery they so desperately need.

Dr. Cook and Vital Health have given me my life back! Less than 4 weeks ago, I came in complaining about chronic pain I’ve been suffering from for 5 years. The pain interfered with every aspect of my life. I went to numerous physicians and underwent several surgeries that accomplished little. Dr. Cook was able to identify my issues, listen (really listen) to my complaints, and fix my problem.Julia
Patient