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
What is pelvic dissection in endometriosis surgery?
Pelvic dissection in endometriosis surgery means carefully separating and opening tissue planes in the pelvis so we can clearly see normal anatomy and remove disease safely. Endometriosis can cause inflammation and scarring that “glues” organs together (sometimes called a frozen pelvis), so dissection is often the step where we free adhesions and restore normal relationships between the uterus, ovaries, bowel, bladder, and pelvic sidewalls.
In practical terms, pelvic dissection may include identifying and protecting critical structures like the ureters, bladder, bowel, blood vessels, and pelvic nerves before excising endometriosis at its roots. This is where surgical precision matters: the goal is to fully address disease while minimizing injury to healthy tissue, especially in complex or re-operative cases. If you’re seeing this term on an op note or surgical plan, it usually reflects the complexity of the anatomy and the deliberate work needed to make excision both complete and safe—our team can walk you through exactly what was dissected and why in your specific case.
What does a frozen uterus mean with endometriosis?
A “frozen uterus” isn’t a separate diagnosis—it’s a descriptive term surgeons use when the uterus is essentially stuck in place because endometriosis-related inflammation has caused dense scarring (adhesions). Instead of the uterus moving freely, it may be tethered to nearby structures like the bowel, bladder, ovaries, or pelvic sidewall, sometimes pulling the uterus into an abnormal position and making pelvic anatomy hard to distinguish.
This finding often suggests more advanced disease, such as deep infiltrating endometriosis and/or significant adhesions from prior inflammation or surgery, and it can help explain symptoms like deep pelvic pain, painful sex, bowel or bladder symptoms, or pain that doesn’t match what a routine exam shows. In these cases, surgery is less about “burning spots” and more about carefully restoring normal anatomy—freeing organs, protecting ureters and bowel, and removing endometriosis at its roots. If you’ve been told your uterus is “frozen,” our team can help you understand what that implies for imaging, surgical planning, and which adjacent organs may need to be evaluated as part of a complete excision strategy.
What are peritoneal pockets in endometriosis?
Peritoneal pockets are small “indentations” or fold-like defects in the peritoneum—the thin lining that covers the pelvic organs and inner abdominal wall. In endometriosis surgery, we may see these pockets as tucked-in areas or little pits in the peritoneal surface, and they can be associated with superficial peritoneal endometriosis or early/developing disease patterns.
These pockets matter because endometriosis doesn’t always look like obvious black or red implants; it can hide within subtle anatomic changes, scarring, or altered peritoneal contours. In the operating room, careful inspection and technique are important so that disease within or around a peritoneal pocket isn’t missed or only treated on the surface. If you’ve been told you have “peritoneal pockets,” our team can help you understand what that finding may mean in your case—based on your symptoms, imaging, and whether deeper structures (like bowel, bladder, or ureters) could also be involved.
Can endometriosis spread to the brain?
Yes—endometriosis can occur outside the pelvis, and it has been reported in distant parts of the body. That said, brain involvement is extremely rare compared with pelvic disease or even other extra‑pelvic locations like the diaphragm and chest.
When people worry about “endo in the brain,” it’s often because they’re experiencing neurologic symptoms (headaches, nerve-type pain, numbness/weakness) that seem to flare with their cycle. Sometimes those symptoms are related to endometriosis affecting nerves or areas higher in the abdomen/chest rather than the brain itself, and the cyclical timing can be an important clue. If you have unusual symptoms that track with menstruation, our team can help you think through the full-body picture, determine what’s most likely, and map out next steps for accurate diagnosis and treatment—including minimally invasive excision when appropriate.
Can I fly with a large endometrioma?
Yes—many people can fly with an endometrioma, even a large one, but “safe” depends on your individual risk profile and symptoms. The main in-flight concern with a larger ovarian cyst is an acute complication like torsion (the ovary twisting) or, less commonly, rupture—events that can happen on any day, but feel especially stressful when you’re far from care. Cabin pressure changes aren’t known to make endometriomas expand, but dehydration, constipation, prolonged sitting, and limited access to pain control can make a pelvic pain flare much harder to manage mid-flight.
If you’re having escalating one-sided pelvic pain, significant nausea/vomiting, fevers, dizziness/faintness, or pain that suddenly becomes severe, we generally want you evaluated before you travel—those can be warning signs that change the plan. If you do fly, think through logistics that reduce strain: choose an aisle seat if possible, plan for gentle movement and hydration, and have a clear pain plan for the travel day so you’re not improvising at 30,000 feet. If the endometrioma is growing, very symptomatic, or affecting fertility planning, our team can help you map next steps—whether that’s careful monitoring, symptom control while you travel, or discussing targeted treatment options designed to treat the disease rather than just chasing flares.
What are signs endometriosis has returned after surgery?
Endometriosis “returning” after surgery can show up as symptoms that improve for a while and then gradually (or suddenly) come back months or even years later. The most common signal is the return of your familiar pattern—cyclical pelvic pain, worsening period pain, pain with intercourse, or pain that starts spreading beyond where it used to be. Some people also notice bowel or bladder symptoms re-emerge (pain with bowel movements, rectal pressure, urinary urgency or bladder pain), especially if those organs were involved before. New or increasing fatigue and activity limitation can be part of the picture, but the key is a clear change from your post-op baseline.
It’s also important to know that recurrent pain doesn’t always equal recurrent disease. Even after complete excision, the nervous system can stay “turned up,” and pelvic floor dysfunction, adhesions, or central sensitization can keep pain going or make normal sensations feel painful—so we think in terms of patterns, triggers, and timing rather than a single pain score. If symptoms are returning, our team can help you sort whether you’re in a true recurrence lane (improved, then returned) versus persistent pain that never fully settled, and decide when imaging (such as ultrasound or MRI) is useful—particularly for tracking ovarian endometriomas. If you’re noticing a shift back toward your old symptoms, reach out to schedule a consultation so we can build a clear, long-term follow-up plan with you.