The gold standard for diagnosis of endometriosis, a chronic, debilitating condition impacting millions of women (XX), is minimally invasive surgery with histological confirmation. Due to advancements and understanding of the disease, we now recommend that surgical treatment of the lesions be performed at the same time as a diagnostic surgery. It is well understood and agreed upon that in order to obtain a biopsy, the tissue must be removed and excised for analysis but the type of surgical approach to address the lesions is not consistent among all practitioners.
If you were to ask someone well versed in endometriosis such as an endometriosis excision surgeon or even a patient advocate who is well up to date on their understanding and research, you’d likely hear that excision surgery is the gold standard for treatment and the preferred approach is minimally invasive. However, there are still those who would provide a counterargument stating that there is a place for ablation, especially, according to some guidelines, in the pediatric and adolescent age group. Those who proffer minimally invasive excision surgery differ in opinion about the adequacy of older technology laparoscopy vs. the technical benefits of robotically assisted enhancements.
This article aims to provide some insight as to the understanding and nuances behind these arguments, and the limitations in the current research, as well as provide a comprehensive guide on the different treatment approaches for endometriosis, including excision surgery, robotic surgery, and the role of ablation.
Endometriosis is a heterogeneous, inflammatory condition where endometrial-like tissue is found throughout the body, typically in the abdominopelvic cavity. While some patients with endometriosis can remain asymptomatic, an estimated 35-50% experience severe pelvic pain, infertility, and other symptoms related to the location of the endometriosis lesions or implants. Endo is intensely inflammatory and fibrogenic, which often creates huge anatomic distortion, causing infertility and pain. Tackling endo surgically requires advanced skills for these reasons.
Current and Future Treatment Approaches for Endometriosis
Today’s treatment options are largely limited to hormonal manipulation and surgery. According to various medical advisory organizations, medical therapies should be offered as first-line therapies to alleviate endometriosis symptoms and potentially treat the endo, and then surgical intervention becomes an option. Sometimes surgery is only offered when pain is not alleviated, potentially allowing the endometriosis and resulting fibrosis to grow.
There is a strong counterargument to starting with medical/hormonal therapy, which is often initiated based on clinical symptoms and findings that suggest endometriosis may be present. Leading with medical treatment, which can have significant and lasting side effects, means potentially injurious and ineffective treatment can be prescribed when in fact there is no endometriosis present. In addition, due to relative progesterone resistance, symptoms may be ameliorated but the aberrant endometriotic tissue is not usually eradicated. Meanwhile, fibrosis from your body’s healing efforts continues to accumulate. Therefore, excision may be considered a cornerstone initial step to remove the macroscopically evident bulk of disease followed by potential preventive strategies to suppress any residual microscopic disease after the diagnosis is pathologically established.
Excising all visible lesions, associated adhesions, and scarring or fibrosis, is thought to reduce disease recurrence, relieve pain, and enhance fertility rates. However, while this can provide long-term relief, it is not usually curative. In complex endometriosis cases (stage III or IV according to the revised American Society for Reproductive Medicine classification), achieving the goal of safe and complete excision of visible lesions, especially using conventional laparoscopy can be technically challenging, and requires specialized training.
While this article is not focused on other treatment options, keep in mind that holistic, nutritional, Eastern and natural approaches have a role in alleviating symptoms and, to a degree, can influence the course of endo as well.
Future treatments on the horizon will go far beyond surgery and hormonal manipulation. We already know that there are other molecular pathways that drive endo growth and these will eventually be effectively harnessed for diagnostics, monitoring, and treatment. Some of these pathways can already be influenced by nutritional and other holistic methods.
Excision Surgery for Endometriosis
Excision surgery, most often performed via laparoscopy or robotics, has largely replaced ablation and big incision surgery. There is general agreement that minimally invasive surgery is superior to big incision (laparotomy) type of surgery. However, ablation is still commonly performed, partly because it is simply easier and requires far less skill.
During excisional surgery, visible endometriosis lesions are removed, which studies have shown significantly reduces the rate of disease recurrence and associated pelvic pain. However, not all studies clearly support excision over ablation. Additional research is required to settle this question and this is very difficult to do because of the extremely wide variance of surgeon skill. Suffice it to say that publications by experts in excisional surgery seem to clearly support this technique over ablation.
The technical aspects of laparoscopy and robotics, as well as the surgeon’s expertise, dexterity, surgical precision, coordination, and visualization limitations, can cause complications during surgical dissection to vary widely, particularly in severe endometriosis cases. For this reason, it is prudent that a surgeon trained in specialized excision techniques perform these surgeries to minimize complications as well as to ensure adequate removal of all visible lesions.
Robotic Surgery for Endometriosis
Over the past fifteen years, robotically enhanced surgery has emerged as an additional tool that can help circumvent the technical challenges of conventional laparoscopy. It offers several advanced features, including 3-D and magnified visualization, wristed instruments, motion scaling, and ergonomic positioning for the surgeon. But what does this mean in terms of benefits to you as the patient?
First, 3-D technology and magnified view mean that the surgeon can see every little detail which conventional 2-dimensional laparoscopy may not allow the surgeon to discriminate, even using so-called “near contact laparoscopy.” This is because magnified 3-D allows depth perception so that even sub-millimeter irregularities on the peritoneal surface can be identified. Also, in a difficult case with distorted anatomy, it allows the surgeon to better avoid damaging adjacent organs, like the bowel and ureters.
Second, the instruments at the tips are “wristed”, meaning they behave like tiny human hands. Conventional laparoscopic instruments are straight sticks with scissors or graspers at the end, which can limit options in tight spaces to cut, push, pull and tear. Robotic wristed instruments can result in more precise motions to excise endo in difficult places and avoid bleeding and other complications.
Third, the fulcrum of activity during conventional laparoscopy is the abdominal wall. When the surgeon moves the instruments, because of their straight nature, the abdominal wall is constantly being tweaked and traumatized. In contradistinction, since the surgical activity fulcrum is at the instrument tips during robotic surgery, there is less ongoing trauma to the abdominal wall. This results in less abdominal wall pain over the first hours and days after surgery.
Fourth, the risk of needing to convert to a big incision because the surgery is not going well using minimally invasive surgery is higher for laparoscopy compared to robotics. So, you have twice the risk of waking up with a much bigger incision during a planned conventional laparoscopy. Big incisions are prone to hernia and infection, not to mention more painful during recovery. Generally, the more difficult the surgery the higher the conversion risk. Unfortunately, it is not possible with endometriosis (due to its intensely inflammatory and scarring nature) to accurately predict what is going to be an easy vs difficult surgery. This is truly a case of an ounce of prevention (optimal preparedness) being worth a pound of cure (getting caught with inadequate instruments for the job and then trying to scramble and fix it).
Research Comparing Robotic Surgery with Conventional Laparoscopy
Several studies have been conducted to compare the efficacy of robotic surgery and conventional laparoscopy in treating endometriosis. A meta-analysis by Chen et al. evaluated the safety and efficacy of robotic surgery for treating advanced-stage endometriosis. The study concluded that while robotic surgery was safe and efficient, it was also time-consuming and incurred higher costs compared to conventional laparoscopy. Studies like this are hard to interpret because it is not possible to know the real skill base of the surgeons involved, which means conclusions about costs and efficiencies are suspect. Also, it’s important to keep in mind that from the patient’s perspective, this cost is irrelevant. The costs are almost all absorbed by the hospital or surgery center and not directly passed on to the patient.
The bottom line is that an experienced laparoscopic excision surgeon will likely be able to get the right surgery done safely in straightforward and moderately complicated cases. A robotic surgeon should be vested enough in the newer technology (i.e., does a lot of robotic surgery, if not all robotics) to realize a difference. In other words, in most cases, the surgeon is the most important part. However, due to the superior technology, a highly skilled robotic surgeon will likely complete a complicated case safely (e.g., Stage III or IV with multiple prior surgeries), without conversion to a big incision, more often than a highly skilled laparoscopic surgeon, due to the limitations of inferior technology.
From a practical perspective, you can experience/simulate the difference yourself between 2-D and 3-D vision or between straight stick laparoscopic surgery vs wristed robotics technology. Wear a patch or tape one eye closed and immobilize your elbows and wrists with splints and tape, leaving only two fingers to grasp things with, and go about your daily business (NOTE: please don’t do this without someone assisting you because you will find that you misjudge distances and are unable to carry out tasks safely). Can you adjust to this handicap over time? Of course, as can a surgeon. However, it is certainly not optimal to avoid using your wrists and both eyes if you have a choice.
Robotic Surgery for Deep Infiltrating Endometriosis (DIE) and Extragential Endometriosis
DIE is a severe form of endometriosis characterized by endometrial tissue growth more than 5mm deep into the peritoneum. Approximately 40% of patients with endometriosis suffer from DIE. DIE can cause dense adhesions and fibrosis, distorting pelvic structures, including genital organs, the bowel, and the urinary tract, causing severe pelvic pain. There is also an overlap of molecular abnormality markers (primarily ARID1A mutations) between DIE and clear cell cancer arising from endometriosis. This has led researchers to suggest that the DIE type of endo is pre-malignant. Removing DIE requires an even higher skill base, and robotics can facilitate far safer and complete surgery for the reasons noted above.
Ablation for Endometriosis
Let’s consider the technique of ablation, as opposed to excision, in a little more detail. This procedure involves destroying endometrial lesions using heat or laser energy rather than removing them. This method was introduced in the 70’s but has significant limitations. The issue with ablation is that while it may be adequate for very superficial disease, it does not remove the lesion, and more importantly, you cannot determine how deep the lesion goes by burning the surface and not carefully excising the lesion. Ultimately this can leave behind endometriosis which can continue to wreak havoc on the body. In addition, the more trauma to your body (ablation via thermal damage is more traumatic than precise excision), the more your body resorts to scarring and fibrosis for healing. This fibrosis can continue to cause pain and lead to complications like urinary system obstruction. Finally, the ureters ( tubes that connect your kidneys to your bladder) and bowel are often right underneath endo lesions. These are thin, delicate structures that are in danger of damage by thermal spread. If they leak due to damage this can lead to emergency surgery, colostomy (wearing a bag for stool on your belly), urinary reconstruction and even death. Therefore, it should only be done in circumstances where the risk is low, such as the eradication of tiny endo superficial ovarian lesions when all else (including endometriomas) has been excised.
Regardless of the approach to excision – robotic or conventional laparoscopy, the need for better research utilizing highly skilled surgeons performing wide-excision is needed to definitively demonstrate the superior overall benefits compared to ablation surgeries. As of now, research is relatively sparse due to flaws in the research process discussed in this article and many more statistical reasons. Again, we are burdened by a lack of superlative surgeons and this is not a surgery for less skilled surgeons to dabble in, whether it be in research study participation or patient care. As a result, the lack of absolute positive outcome superiority currently impacts the availability and insurance reimbursement for those seeking a safe and effective excision surgery. At this time, since everyone’s situation is different, the best course of action is to get an expert opinion from the best endometriosis specialist you can find.
Looking for a specialist? Check out our related blogs:
- Finding an Endometriosis Specialist: Your Guide to Effective Treatment
- Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery
N.B. The above is based on a combination of published data and the author-surgeon’s personal experience, spanning over three decades, using both laparoscopy and robotic surgery for advanced excisional surgery, inclusive of advanced endometriosis and radical cancer excision.
- Pundir, J., Omanwa, K., Kovoor, E., Pundir, V., Lancaster, G., & Barton-Smith, P. (2017). Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis. J Minim Invasive Gynecol, 24(5), 747-756. https://doi.org/10.1016/j.jmig.2017.04.008
- Kang, J.-H., & Kim, T.-J. (2020). The role of robotic surgery for endometriosis. Gynecologic Robotic Surgery, 1(2), 36-49. https://doi.org/10.36637/grs.2020.00045