Imaging for Surgery

It’s very common for surgery to reveal more endometriosis than ultrasound or MRI suggested. Imaging is best viewed as a tool to estimate likelihood and to map certain higher-risk areas for surgical planning—not a reliable “yes/no” detector for every lesion. Many endometriosis lesions are simply hard to visualize on scans because they can be small, superficial, hidden by normal anatomy, or located in areas where imaging performance varies (and where interpretation depends heavily on technique and experience).

Another reason is that scans are better at identifying some patterns—like ovarian endometriomas or certain deep bowel disease—than they are at detecting disease on ligaments, the bladder/anterior compartment, or in complex multi-compartment cases. Imaging also can’t always capture the full extent of adhesions, scar-like tissue, or subtle inflammatory changes that may become obvious only when the pelvis is directly inspected during laparoscopy.

When we plan surgery, we use imaging as one piece of the puzzle alongside your symptom story, exam findings, and overall pattern—because the goal is safe, complete mapping and excision when appropriate. If your operative findings didn’t “match” your scan, it doesn’t mean the imaging was pointless or that your symptoms were exaggerated—it usually reflects the known limits of what scans can show. If you’re trying to make sense of your results or next steps, our team can help you review what was found, what was removed, and what else (like adenomyosis or coexisting pain drivers) may still need to be addressed.

Usually, no bowel prep is needed for a standard transvaginal pelvic ultrasound used to evaluate suspected endometriosis. Most patients can eat, drink, and take medications as normal unless the imaging center gives you different instructions, and the key is simply arriving with whatever bladder filling they request.

Bowel prep is more commonly discussed when we’re specifically trying to “map” suspected bowel deep endometriosis—especially rectal involvement—using specialized imaging like an endorectal ultrasound, or when a radiology team has a particular protocol designed to improve visibility of the bowel wall and surrounding tissues. If your symptoms suggest bowel involvement, our team focuses on choosing the right type of imaging (and the right interpretation) so the results actually help guide next steps.

If you’re unsure what test you’re scheduled for, reach out to confirm whether it’s a routine transvaginal ultrasound or a bowel-focused study and what preparation, if any, is expected. We can also help you decide whether additional mapping would be useful based on your symptom pattern and exam findings.

“Restricted sliding” on a pelvic ultrasound usually refers to a limited “sliding sign,” meaning nearby pelvic structures don’t glide smoothly against each other when gentle pressure is applied with the ultrasound probe. In a typical pelvis, organs like the uterus, ovaries, bowel, and the space behind the uterus (often called the pouch of Douglas) should move freely relative to one another.

When sliding is restricted, it can suggest adhesions (scar tissue) or deep endometriosis that is tethering tissues together—sometimes described as “fixed” anatomy. It’s not a diagnosis by itself, and it doesn’t tell us the full extent of disease, but it’s a meaningful clue that can help guide next-step imaging and—if surgery is being considered—preoperative planning. If your report mentions restricted sliding along with symptoms like deep pelvic pain, painful sex, pain with bowel movements, or cyclical bowel/bladder flares, our team can help interpret what that combination may mean in your specific case and what evaluations are most useful next.

On pelvic MRI, “T2 dark plaque” describes an area that looks dark on the T2 sequence (a common MRI setting that highlights fluid and soft-tissue differences). Radiologists often use this phrase when they see a plaque-like region of low T2 signal that suggests dense, fibrotic tissue—often scar-like change—rather than a simple fluid-filled cyst. In the endometriosis world, low T2 signal plaques can be seen with deep infiltrating disease or adhesions, because chronic inflammation can lead to fibrosis that reads “dark” on T2.

That said, “T2 dark plaque” is a descriptive imaging term, not a diagnosis by itself. Its meaning depends on the exact location (for example, behind the uterus, along the uterosacral ligaments, near the bowel or bladder) and whether there are other supportive MRI features, since some benign non-endometriosis processes can also look T2-dark. If your report mentions a T2 dark plaque and you have symptoms that fit organ involvement (bowel, bladder, deep sex pain, severe cyclical pelvic pain), our team can review your imaging and history together and help you understand whether the finding is likely clinically significant and how it may affect next steps in treatment planning.

Sometimes—especially if imaging or exam suggests deeper rectal or sigmoid involvement and there is a real possibility that the bowel wall may need to be opened, repaired, or resected. Bowel endometriosis can range from superficial implants on the outer surface of the bowel to deep disease that infiltrates the muscular layers and narrows or distorts the lumen; the deeper it goes, the more important it is to have a team that can safely handle bowel entry, suturing, stapling, and anastomosis if needed. In most cases a general surgeon or colorectal surgeon is required with the exception of a team including or your primary surgeon being a gynecologic oncologist. All three are credentialed in bowel surgery.

In many patients, bowel-type symptoms come from inflammatory pelvic disease and adhesions even without full-thickness bowel involvement, and surgery may be limited to careful excision off the bowel surface (“shaving”) without requiring a formal bowel procedure. The decision is ideally made with pre-op mapping (often ultrasound and/or MRI) and a plan that matches your anatomy—so you’re not surprised in the operating room by a higher-risk bowel step that wasn’t anticipated.

In our practice, we have a unique offering in that Dr. Vasilev is a gynecologic oncologist who is trained and credentialed to perform bowel surgery. We plan bowel endometriosis surgery around safety and completeness, using robotic excision for precision, and we coordinate the right surgical partners when the imaging, exam, or history suggests a disc excision or segmental resection could be on the table. For example, there may be evidence of other disease like diverticulosis or other bowel findings. If you tell us your symptoms and what your imaging shows (or if you’re unsure), our team can help you understand whether a colorectal surgeon should be involved from the start and what that means for recovery and outcomes.

Follow-up imaging isn’t on a single fixed schedule—it’s individualized based on what we’re monitoring. We use ultrasound and/or MRI most when it will change decisions, such as tracking ovarian endometriomas, mapping suspected deep disease (bowel/bladder/uterosacral involvement), or evaluating adenomyosis or a new pelvic mass. It’s also important to know that symptoms and imaging don’t always match, so the goal is not “scanning on a timer,” but getting the right test at the right moment.

In many cases, a practical framework is a baseline post-op check once initial healing is complete (often around 6–12 weeks), a planned reassessment around 6–12 months, and then annual follow-ups—especially if you had endometriomas, deep infiltrating disease, or persistent symptoms. Imaging may not be needed at every visit, but we’re more likely to recommend it when symptoms change, when prior imaging was incomplete, or when we need a clearer multi-compartment map to guide next steps. If you share your prior imaging reports (and images if available), our team can tell you what’s worth repeating, what’s not, and how often surveillance makes sense for your specific pattern and goals.

An endometriosis ultrasound mapping exam is a specialized pelvic ultrasound performed with the specific goal of “mapping” where endometriosis is suspected—not just checking whether a cyst or mass is present. In experienced hands, it looks for signs of deep endometriosis and evaluates key areas like the ovaries, uterosacral ligaments, the pouch of Douglas, and whether there are findings that suggest bowel involvement or reduced organ mobility from adhesions.

Mapping matters because endometriosis isn’t simply yes-or-no; surgical planning depends on location, size, and how deeply disease may involve surrounding structures. In some situations—especially when rectal endometriosis is suspected—your evaluation may include more than one ultrasound approach, such as transvaginal ultrasound and, when needed, an endorectal ultrasound to better assess the rectal wall layers.

We use imaging as one piece of a comprehensive evaluation that starts with your full symptom story and a careful exam, because imaging can miss disease or under-describe what’s driving your pain. If you’re considering surgery or have complex symptoms, our team can help you understand what a mapping exam can (and can’t) tell us and what information we still need to plan the safest, most effective next step.

Bring any records that help us understand what’s already been tried and what your body has shown so far. The most useful items are operative reports from any prior pelvic or abdominal surgeries, pathology reports (especially if endometriosis was confirmed), and imaging reports from ultrasound, MRI, CT, or colonoscopy/urology testing if you’ve had them. If you can obtain the actual imaging files (on a disc or as a download link), those can be even more helpful than the written report alone.

We also encourage you to bring a brief treatment timeline: your main symptoms and flare patterns, medications or hormonal therapies you’ve tried (and what happened), prior diagnoses, and any fertility history if relevant. If you don’t have everything, don’t let that stop you—send what you have, and our team will tell you exactly what additional records would make the consultation most meaningful and efficient. If you’re ready to move forward, reach out to schedule and we’ll guide you through what to submit first.