Gynecologic Oncologists - Safest Choice for Complex Endometriosis Surgery?

Understanding Why Surgeon Training Matters for Endometriosis Care

Endometriosis is inherently very unpredictable. Even with excellent imaging and careful evaluation, the true severity of the disease often isn’t fully known until the minute surgery begins. It can hide behind organs, wrap around the bowel or ureters, distort anatomy, turn into fibrosis reminiscent of a concrete block, mimic other conditions, or spread farther than imaging can reveal --- especially problematic if spread is into the upper abdomen. As a result, cases that appear moderate beforehand may prove far more complex during surgery, and that level of complexity requires a surgeon with advanced training.

This is where the training of your surgeon becomes critically important, because handling advanced disease safely depends on a depth of surgical experience that not all specialists possess. Yes, a team of various speciality surgeons can salvage situations, IF they are available. When advanced disease is not suspected, the risk is that availability might be limited.

Why Would a “Cancer Surgeon” Operate on Endometriosis?

Many patients understandably wonder why a surgeon trained in cancer care would be involved in treating endometriosis. Even though “gynecologic oncology” sounds like a cancer-only specialty, these surgeons are actually fellowship trained at the highest ACGME accredited level of pelvic surgery that exists within all of gynecology.

Their training covers:

• • advanced retroperitoneal anatomy
  • multi‑organ dissection and reconstruction from pelvis to diaphragm
  • complex adhesions and frozen pelvis cases
  • safe mobilization of the bowel and ureters
  • management of emergencies or difficult revision surgeries

This makes gynecologic oncologists uniquely capable of handling cases where the disease turns out to be more widespread than expected. So although the name focuses on cancer, the skill set is extremely relevant — and often essential — for difficult endometriosis cases. You do not need to have cancer to benefit from that level of expertise.

It is no secret that medical groups, hospitals, individual gynecologists and even MIGS surgeons highly depend upon gynecologic oncologists to be available for management of difficult situations like hemorrhage, extremely distorted anatomy due to infection or disease, complications management and so on. Advanced endometriosis is part of this spectrum of needs.

Why This Matters for You: “Better to Have It, and Not Need It”

Many endometriosis surgeries look straightforward at first, but once you’re on the operating table, things can change quickly. If your surgeon encounters extensive disease — such as deep infiltrating endometriosis, organ involvement (bowel, bladder, ureters), dense scarring from prior procedures, or even a frozen pelvis — they must be able to address it immediately and safely. When they cannot, patients may face incomplete surgery, the need for a second operation, higher complication rates, or disruptions to anatomy that can affect long‑term outcomes through complications.

A surgeon with the highest level of pelvic surgical training can adapt safely and effectively, even if your disease turns out to be far more extensive than expected. That’s why choosing a surgeon with maximal training is not about assuming your case will be severe — it’s about being fully prepared if it is.

“I Don’t Have Cancer… Shouldn’t I See a General GYN or MIGS Surgeon?”

It is a natural question, and one that highlights how confusing and misleading specialty names in medicine can be, but the fact is that endometriosis behaves more like a complex infiltrative disease (very much like cancer) than a simple benign condition. It often affects multiple structures — including reproductive organs, the bladder, bowel, ligaments, nerves, and deeper compartments like the retroperitoneum where the ureters, nerves and large blood vessels live— which is why it requires a surgeon who can navigate all of these areas confidently.

This is why gynecologic oncology surgeons hands down are the best trained to surgically treat extensive multi-organ or multi-site pelvic disease — including endometriosis. Some general gynecologists or minimally invasive surgeons (MIGS trained) may be excellent for routine, straightforward or even moderately complex cases. But when there’s risk of deeper disease, organ involvement, or significant fibrotic scarring, the expertise of a highly trained pelvic surgeon becomes crucial.

To round out full disclosure, the vast majority of gynecologic oncologists do not study endometriosis and are not experts in the A to Z management of endo. Nor are all gynecologic oncologists experts in minimally invasive surgery for advanced cases of cancer or benign disease like endo, whether it be laparoscopic or robotic. In the right situation most can still can play a very important role for difficult surgical situations.

Why Lotus Endo Is Different

At Lotus Endometriosis Institute, we offer something beyond this and truly unique: Dr. Steven Vasilev, a gynecologic oncologist who devotes his surgical practice exclusively to endometriosis, adenomyosis and cancers that can be related in those with a family history, genetic anomies or are simply older. Along those lines he has a special skill set in robotic advanced ovarian cancer resection called cytoreduction which is quite like endometriosis excision surgery, except perhaps worse because life and death are on the line. He is not the only one, but only a relative handful of gynecologic oncologists internationally possess this additional minimally invasive excision expertise for advanced cases.

Dr. Vasilev's full focus has also been understanding endometriosis and adenomyosis at a deep clinical and molecular level, crafting evidence supported treatment plans and operating on the most complex patterns of endometriosis. Patients receive the full benefit of a surgeon whose expertise is surgically elite, and unusually specialized. Very few surgeons combine this level of training and experience with such a dedicated clinical and research focus, which further distinguishes the care offered at Lotus.

In short, many people travel from outside California for care here at Lotus Endometriosis Institute because of the elite expertise as well as the holistic integrative approach we incorporate to help you thrive.

The Takeaway for Patients

Choosing a surgeon for endometriosis shouldn't be about labels; it’s about capability and preparedness for every level of complexity, especially when the true extent of disease often isn’t known until surgery begins.

A surgeon with the highest level of pelvic surgical training:

• • keeps you safer
  • increases the chances of finishing the surgery in one operation
  • protects vital organs
  • preserves fertility when possible
  • manages unexpected findings without hesitation

And when that surgeon uses those elite skills exclusively for endometriosis and adenomyosis — like Dr. Vasilev at Lotus — you receive a level of care that is both rare and exceptionally effective. If your goal is the best possible long-term outcome, choosing the most highly trained pelvic surgeon simply gives you the greatest margin of safety and the strongest likelihood of a comprehensive, durable result.

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Footnote:

The interested reader is highly encouraged to fact-check the following summary in case they are concerned that their case may be difficult due to findings on imaging, a frozen pelvis on exam, or recurrence and inevitable reactive fibrosis:

Here is an objective summary of the surgical training metric differences:

GYN/ONC (Gynecologic Oncology): This is a standardized, ACGME-accredited specialty resulting in board certification in both Obstetrics & Gynecology and Gynecologic Oncology. The curriculum nationally mandates extensive training in navigating and resecting disease from vital organs (bowel, bladder, ureters, major blood vessels, diaphragm) and managing surgical complications in highly complex anatomical scenarios. A GYN/ONC surgeon has a uniformly verified, high baseline of training for severe surgical difficulty.

MIGS (Minimally Invasive Gynecologic Surgery): This is a post-residency fellowship accredited by the AAGL, which relies more heavily on the mentorship model (an apprenticeship). Most programs are not exclusively focused on endometriosis, but it is certainly almost always part of the training to a variable degree. As of 2025 there is no national, ACGME-enforced standard curriculum or board certification specifically for "MIGS" that guarantees exposure to every type of multi-visceral (multi-organ) dissection or resection. The quality and volume of complex cases encountered vary significantly from one program to another.

In objective summary terms:

It is statistically more difficult to determine the surgical competency of a MIGS surgeon for a highly distorted anatomy endometriosis case before the procedure begins compared to a GYN/ONC surgeon, because the MIGS training metrics lack external, uniform ACGME oversight to determine the background training rigor and experience. The GYN/ONC designation and board certification objectively signals a higher, standardized baseline of training for complex anatomy management, regardless of whether the disease being removed is benign or malignant.

The caveat, as always, is that within ANY speciality there are surgeons who are far better or far worse than average. Thus there are certainly exceptions to the summary analysis, especially after experience of any given surgeon grows over the years. The secondary caveat is that there are very few gynecologic oncologists who focus on or exclusively manage endometriosis and adenomyosis. However, there are certainly many MIGS surgeons who were not trained with that focus either. The tertiary caveat is that a MIGS trained surgeon working as part of a team with general surgeons and urologists, who must also possess higher level minimally invasive skills, can get the job done. However, there is a higher risk of a weak link and availability of multiple surgeons for any given case. An integrated "team" is one thing, but a loose collection of various surgeons does not make a cohesive "team".