Surgery & Advanced Excision
Next level excision done right, relief that lasts.
Lasting Relief Starts Here
Surgery First, Done Right
Surgical excision is the cornerstone of endometriosis treatment and as of today it remains the only way to definitively diagnose the disease. At the Lotus Endometriosis Institute, we rely on robotic excision as the surgical approach of choice, using superior 3-D optics and wristed instruments that allow meticulous precision far beyond standard laparoscopy. This potentially translates into fewer complications, faster recovery, and excellent outcomes—even in advanced and re-operative cases. As a result, patients with the most complex endometriosis cases are frequently referred to us from across the country. With over 30 years of experience, Lotus Institute's lead physician and world-class surgeon Dr. Steve Vasilev brings unparalleled expertise in delicate abdominal-pelvic surgery involving the bowel, bladder, and ureters.
Robotic Excision, Without Compromise
Our Surgical Approach
At Lotus Endometriosis Institute, we don’t use standard laparoscopy or partial measures. Robotic excision is our exclusive approach because it allows unparalleled precision, safety, and completeness in removing endometriosis. Every detail—from optics to instruments—serves one purpose: delivering the best possible outcomes for our patients.
What is it?
Robotic Surgery
Robotic surgery is the most advanced form of minimally invasive surgery. Using the DaVinci robotic system, your surgeon operates from a console that controls tiny wristed instruments, each capable of movements more precise than the human hand. The system’s high-definition 3-D optics magnify the anatomy up to 10 times, so even small, flat endometriosis lesions can be seen and removed. Unlike standard laparoscopy, where "straight stick” instruments are limited to grasping, cutting, pushing and pulling, robotic instruments move with natural wrist-like motion. For patients, this often translates into greater accuracy, fewer accidental injuries, and less strain on the body due to less manipulation at the abdominal wall.
Adapting to Your Needs
Tailored Surgical Care
Endometriosis doesn’t look the same in every patient, and surgery must be adapted to each individual. Disease can appear on the peritoneum, ovaries, uterus, tubes, bladder, large and small bowel, including the appendix, diaphragms and beyond. Each situation requires a different strategy, especially when older or at higher genetic risk for malignant degeneration.
For some, conservative excision preserves fertility by removing only diseased tissue while sparing vital structures. For others, especially those no longer planning pregnancy, more definitive procedures—such as hysterectomy in the presence of adenomyosis—may provide lasting relief. Ovarian endometriomas or “chocolate cysts” often demand careful dissection, while severely damaged Fallopian tubes may need removal to reduce the risk of dangerous ectopic pregnancy or inflammatory fluid back-leaking into the uterus which impair embryo implantation.
In select cases, additional procedures like appendix removal may be prudent, as endometriosis or other pathology can involve this organ. Rarely, large nerve procedures (e.g. sciatic) are considered, though only in highly specific circumstances. More commonly, smaller nerves such as the hypogastric plexus, genitofemoral and pudendal nerves require dissection and preservation. Whatever the presentation, the goal remains the same: remove as much disease as safely possible, protect function, and tailor the plan to each patient’s needs and future goals.
Organ-specific considerations include:
Ovaries: Meticulous excision or limited bipolar micro-ablation to preserve tissue; removal may be necessary for severe multiple endometriomas or suspected tumors.
Uterus: Adenomyosis may require hysterectomy if fertility is not a goal; otherwise, conservative approaches are used.
Fallopian Tubes: Severely damaged tubes may be removed to prevent ectopic pregnancy and improve durable embryo implantation rates.
Appendix: Individually assessed and sometimes removed due to endometriosis involvement, risk of appendicitis, or hidden pathology.
Nerves: May be addressed via surgery when neuropelveologic pain mapping and imaging or surgical findings support excision surrounding specific nerves
Diaphragms and Upper Abdominal Surgery: Resection of disease in the upper abdomen, including superficial and deep excision of diaphragmatic endo, is always possible and few gynecologic surgeons are capable of this type of surgery. At Lotus we have you covered up to and including the diaphrgam, and bring in thoracic surgery if lung disease is also suspected.
Healing You Can Count On
Recovery & Lasting Results
Excision done with robotic precision doesn’t just make surgery safer—it transforms recovery. Smaller incisions, less trauma, and more complete removal of disease all add up to better outcomes that patients can feel immediately and long term.
Small Incisions, Lasting Confidence
Most robotic excision surgeries require just three or four 8mm incisions, often hidden in the belly button or some below the bikini line. These tiny entry points heal quickly, and with proper care, any scars usually fade and are barely noticeable. For comparison, laparoscopic incisions are usually 5mm in size but the recovery difference is negligible and the robotics benefits outweigh this small difference.
Less Pain, Fewer Medications
Because robotic instruments cause less trauma to abdominal wall muscles and tissue, patients typically experience less pain after surgery. Everyone is different but most need little to no narcotic medications after postoperative discharge, which makes recovery smoother and safer.
Faster Return to Life
Patients generally return home the same or next day, begin walking comfortably within a week, and resume work or daily activities in 2–3 weeks. By one month, most are back to full activity.
Relief That Lasts
Unlike ablation, which often leaves disease behind, excision removes endometriosis at its roots. This reduces the need for repeat surgeries and provides long-term relief, especially in complex cases.
Prepared for Every Scenario
Excellence in Complex Surgery
Endometriosis surgery can be straightforward—or extremely complex. In some patients the anatomy is relatively normal, while in others the pelvis is completely scarred and “frozen” from years of inflammation. Prior surgeries, large endometriomas, fibroids, or adenomyosis can make the situation even more challenging. Sometimes the bowel, bladder, or ureters are directly involved as well.
Although rare, endometriosis can sometimes undergo malignant change. If cancer is discovered, the surgical team must be capable of addressing it immediately and safely. This level of preparation ensures that whether surgery turns out to be simple or highly complex, patients receive safe, effective care.
In all of these situations, safe excision requires more than just advanced tools—it demands the judgment of a surgeon trained to handle any scenario. Precision is critical: removing too much can cause complications like fistulas, while removing too little leaves disease behind. The right expertise means balancing these risks carefully and ensuring organs are protected while disease is thoroughly removed. This level of expertise is what the Lotus Endometriosis Institute prides itself on.
Experience You Can Trust
The Right Surgeon Matters
Not all surgeons who treat endometriosis are equally trained or prepared for it. The difference can mean temporary relief versus lasting results. Here’s why most fall short, and who truly has the expertise to handle the complexities of this condition:
General Gynecologists
Most are capable of handling basic gynecologic procedures, but their residency includes limited training in complex excision. Many rely on electrosurgical fulguration or laser ablation, which burns visible lesions but often leaves disease behind. While some gynecologists pursue additional focus on endometriosis after residency, the majority still emphasize medical management with drugs like Lupron or Orlissa rather than advanced surgical care. Compared to general surgery or urology training, which is five to seven years of only surgery, gynecology residency provides the least intensive surgical training due to the competing need to fit in obstetrics training.
Reproductive Endocrinologists (REI)
REIs specialize in infertility and hormonal treatments, not excision surgery. Their fellowships focus on assisted reproduction techniques such as IVF, and most no longer practice the microsurgical skills once part of their specialty. If fertility is your only concern, an REI may play a role in your care—but they are rarely the right surgeon for endometriosis excision. There are exceptions to this generalization.
General/Colorectal Surgeons & Urologists
These surgeons are well trained in their own specialties—bowel, urinary tract, or hernia surgery—but they are not trained in gynecologic surgery or the nuances of endometriosis. They are often brought in as assistants when endo involves the bowel or bladder. In those cases, they may act more as technicians under the gynecologic surgeon’s lead. While collaboration can work, it sometimes leads to disagreement in the operating room about what should be done, and overly aggressive surgery may result (e.g. bowel resection when meticulous dissection can spare bowel in most cases). These specialists rarely provide complete care for endometriosis on their own.
Endo-Excision Surgeons
Some gynecologists pursue additional, non-ACGME accredited fellowships in minimally invasive surgery with very variable endometriosis excision and retroperitoneal dissection requirements. These one- to three-year programs (most are two years) improve surgical skill and generally produce surgeons a definite level above most general gynecologists. But oversight and quality vary, and few receive extensive training in bowel, urinary tract or retroperitoneal surgery. Relatively few can manage these areas; the vast majority cannot and rely on multidisciplinary teams that are variably coordinated. The result is inconsistent capability when endometriosis invades or is even close to delicate structures. So if you are considering a center which relies on teams, make sure it is really a coordinated "team" and not a collection of various surgeons who are not always available or on the same page about the intent of surgery.
Gynecologic Oncologists
Gynecologic oncologists complete three to four years of fellowship beyond Ob/Gyn residency, with the most extensive and rigorous pelvic surgery training available in gynecology. They perform bowel, bladder, and ureter resections as part of cancer operations, making them uniquely capable of handling endometriosis that often behaves like a malignancy. However, most focus primarily on cancer and do not dedicate their practice to benign endometriosis. Thus endometriosis expertise regarding when to do what is usually lacking, so under and over treatment surgically is possible.
Gynecologic Oncologist Focused on Endometriosis — Dr. Steve Vasilev
Dr. Vasilev stands in a category of his own. Quadruple board-certified, with more than 30 years of surgical leadership and international recognition. He combines the unmatched training of a gynecologic oncologist, along with extensive additional multidisciplinary surgical experience, with a long-standing focused commitment to endometriosis excision. Having mastered complex, multi-organ minimally invasive robotic pelvic surgery he applies that expertise to even the most advanced and re-operative endometriosis cases. Patients are referred to him from across the U.S. and internationally because his skill and experience go far beyond what most excision surgeons—or any other surgeon type—can provide.
The best outcomes come from a surgeon who unites technical mastery with deep understanding of how endometriosis behaves and spreads. At the Lotus Endometriosis Institute, Dr. Steven Vasilev and our team apply decades of advanced surgical expertise to restore anatomy, relieve pain, and preserve function with precision and safety—no matter how complex the disease.
Take the Next Step
Your Path to Relief Starts Here
Every case of endometriosis is unique, but the solution begins the same way—with an expert evaluation and a surgical plan tailored to you. Schedule a consultation with Dr. Vasilev and our expert medical care team to review your history, imaging, and goals, and take the first step toward lasting relief.
Common Questions
How is multi-organ endometriosis treated without organ removal?
In many multi-organ cases, the goal is conservative surgery: removing endometriosis while preserving the organs themselves. That typically means meticulous excision of disease from surfaces and deeper planes around the bowel, bladder, ureters, ovaries, and pelvic sidewalls—freeing organs from scar tissue and restoring normal anatomy without taking the organ out. Because endometriosis can hide in distorted or “frozen” anatomy, the safest way to preserve organs is often a highly precise approach that can dissect around vital structures.
In our practice, we use robotic excision to improve visualization and fine-control dissection, which is especially helpful when disease involves multiple compartments or has been operated on before. When endometriosis is close to structures like the ureters, bowel, diaphragm, or certain nerves, treatment planning may include coordinated work with other surgical specialists so the disease can be fully addressed in one operation while still prioritizing organ-sparing techniques.
Organ removal is usually considered only when an organ is severely damaged, there are multiple large endometriomas that can’t be safely managed with tissue-sparing techniques, fertility-safety concerns arise (like a badly damaged tube), or there’s concern for tumor or malignant change. If you’re trying to avoid organ removal, we can help map likely disease sites, clarify your priorities (pain relief, function, fertility), and outline what organ-preserving excision could realistically look like in your specific case—then build a surgical plan around that.
How much time off work do I need after endometriosis surgery?
Most people need about 2–3 weeks off work after minimally invasive endometriosis excision, especially if your job is mainly desk-based and you can ease back in. With robotic excision, patients often go home the same day or next day, start walking comfortably within about a week, and many feel ready for a gradual return to typical daily routines in that 2–3 week window.
The exact time off depends less on the incision size and more on what we need to treat during surgery—for example, ovarian endometriomas, bowel/bladder/ureter involvement, extensive scar tissue (“frozen pelvis”), or additional procedures like appendix removal or adenomyosis-related surgery. More complex, multi-organ cases can mean more fatigue, more activity restrictions, and a higher chance of needing an overnight stay, which can extend the time you’ll want to plan away from work.
In most straightforward recoveries, many patients are back to full activity by about a month. If you tell our team what you do for work (lifting, long shifts, travel, on-your-feet all day vs remote/desk), we can help you plan a realistic time-off request and a safer return-to-work ramp based on the surgical plan we’re building for you.
When is hysterectomy recommended for adenomyosis?
A hysterectomy is typically considered for adenomyosis when symptoms are severe and clearly uterus-driven—most often heavy bleeding (sometimes with anemia), intense cramping, pelvic pressure, and daily quality-of-life disruption—and you’re not planning future pregnancy. It’s the most definitive option because adenomyosis lives within the uterine muscle, so removing the uterus removes the source of the problem.
In practice, we usually weigh hysterectomy most strongly when conservative options haven’t brought acceptable relief, aren’t tolerated, or don’t fit your goals. The decision also depends on the pattern and extent of disease (diffuse adenomyosis versus a more focal adenomyoma that may be removable while preserving the uterus) and whether endometriosis may also be present. If endometriosis is part of the picture, it’s important to know that hysterectomy alone doesn’t treat disease outside the uterus—durable symptom relief depends on addressing all pain generators.
If you’re wondering whether you’re at the point where hysterectomy makes sense, our team can help clarify what’s most likely driving your symptoms, review imaging, and walk you through uterus-preserving versus definitive surgical paths so you can choose the option that best matches your relief and fertility priorities.
What is deep infiltrating endometriosis (DIE) and how is it treated?
Deep infiltrating endometriosis (DIE) is endometriosis that grows deeper into tissue—often described as more than ~5 mm below the surface—and it commonly involves structures like the uterosacral ligaments, rectovaginal space, bowel, bladder, or ureters. Because it can inflame, scar, tether, or even narrow/obstruct nearby organs, DIE may show up as “non-gynecologic” symptoms such as bowel or urinary pain, painful sex, nerve-type pelvic pain, or symptoms that don’t match a routine pelvic exam.
Treatment depends on where the disease is and what it’s affecting, but DIE is the subtype most likely to require specialized surgical planning. When surgery is appropriate, meticulous excision (removing disease at its roots rather than burning the surface) is the gold-standard approach for durable symptom relief and for addressing organ involvement; in complex cases this can include careful work around the bowel, bladder, and ureters. Our team focuses on advanced, precision excision (often using robotic technology) with a tailored plan that prioritizes safety, completeness, and your goals—whether that’s pain relief, fertility, or protecting organ function.
Because DIE can be missed on basic exams and even “normal” imaging, evaluation often requires a higher index of suspicion and the right strategy for mapping disease before any procedure. If DIE sounds like it could explain your symptoms, explore our detailed resources on deep disease and excision, or reach out to schedule a consultation so we can review your history, imaging, and next steps together.
What should I ask at an adenomyosis surgery consult?
At an adenomyosis surgery consult, we want you to leave with clarity on the goal of treatment—are we primarily trying to control heavy bleeding, relieve pain/pressure, protect fertility, or all three? Ask what is driving your symptoms based on your history and imaging (ultrasound/MRI), and whether adenomyosis seems diffuse versus a more localized adenomyoma, because that often changes what surgery can realistically accomplish. It’s also important to ask how often adenomyosis overlaps with endometriosis in cases like yours and whether your surgical plan accounts for both.
Then get very specific about options and tradeoffs: ask whether a uterus‑preserving approach is feasible for you versus whether hysterectomy is the most definitive path, and what symptom relief you can reasonably expect with each. Ask what the anticipated scope of surgery is (uterus only vs. evaluation/treatment of other pelvic sites), what surgical approach will be used (laparoscopic vs. robotic), and how the team plans to maximize completeness and safety in complex anatomy. Finally, ask about recovery logistics—same‑day vs. overnight stay, typical timeline back to daily activities, and what postoperative follow‑up looks like—so you can plan your life around the procedure; if you’d like, reach out and we can review your records and imaging with you and map a surgical plan aligned with your goals.
How do I choose an adenomyosis specialist or surgeon?
Choosing an adenomyosis specialist starts with matching the team’s focus to your goal: controlling heavy bleeding and anemia, reducing pain/pressure, preserving fertility, or pursuing definitive treatment. Because adenomyosis often can’t be confirmed with absolute certainty unless the uterus is examined by a pathologist after hysterectomy, the right clinician is someone who is comfortable working with an “imaging + symptoms” diagnosis and can clearly explain how that uncertainty affects your options. You should feel that your plan is individualized—not a one-size-fits-all default to hormones, or a reflex straight to hysterectomy.
When surgery is on the table, look for a surgeon who routinely performs minimally invasive complex pelvic surgery and can describe what they do when adenomyosis overlaps with endometriosis, adhesions, fibroids, or bladder/bowel/ureter involvement. Ask how they decide between uterus-preserving strategies versus hysterectomy, how they plan to protect organs and manage bleeding risk, and what they do to reduce repeat procedures. Our team takes a coordinated approach—careful pre-op planning, meticulous minimally invasive technique when appropriate, and clear goal-based decision-making—and you can explore our approach on the site or reach out to schedule a consultation to review your symptoms, imaging, and priorities.