Does a Longer Endometriosis Surgery Mean More Complications? What a 2025 Study Found.

Hearing that your minimally invasive surgery for advanced (stage III–IV) endometriosis may take “a long time” can be stressful. Many patients understandably worry that a longer operation automatically means a higher risk of complications.

A 2025 study in BMC Women’s Health looked directly at this question in people undergoing minimally invasive surgery for pathology-confirmed stage III–IV endometriosis at a high-volume, specialized U.S. center—and offers some reassuring, practical insights.

Why surgery can take longer in stage III–IV endometriosis

Advanced endometriosis can involve significant pelvic scarring and distortion and may require more complex surgical steps. The study notes that stages III and IV represent advanced disease and may require complex, sometimes multi-organ procedures. In real life, that complexity often translates into longer operating times.

Study snapshot (what was studied, and where)

• Study type: Retrospective cohort study
• Who: Patients aged 18–51 with pathology-confirmed stage III–IV endometriosis
• What: Minimally invasive surgical treatment for endometriosis
• Where: A high-volume tertiary care center in the U.S.
• When: Surgeries from Nov 1, 2013 to Oct 31, 2023
• Main question: Is longer operative time linked to short-term postoperative complications?
• Secondary question: Is longer operative time linked to overnight hospital admission?

Important note: The provided materials do not include detailed definitions of “short-term,” specific complication types, or the exact operative-time cutoffs beyond percentile thresholds and “each additional 60 minutes.” When information isn’t available, it’s safest not to guess.

Key findings: Operative time and short-term complications

1) Longer surgery time was not linked to more short-term postoperative complications

The study’s primary finding was that longer operative times were not associated with increased short-term postoperative complications in minimally invasive surgery for stage III–IV endometriosis. This held true across multiple operative-time thresholds (including the 50th and 90th percentiles) and when looking at additional time in 60-minute increments.

What this may mean for you: If your surgeon says your procedure may take longer due to complexity, this study suggests that—in a specialized, high-volume setting—a longer time in the operating room does not automatically translate into a higher risk of short-term postoperative complications.

2) Intraoperative complications were higher at one threshold—but postoperative complications were not

At the 50th percentile threshold, the study observed a higher rate of intraoperative complications among longer surgeries. However, postoperative complication rates did not significantly differ across operative-time groups (including higher thresholds like the 75th and 90th percentiles).

How to interpret this carefully: This finding does not mean longer surgery is “risk-free.” It means that in this dataset, longer time wasn’t a clear driver of postoperative complications—even though there was a signal for intraoperative issues at one threshold.

A clear takeaway: Longer surgery increased the chance of an overnight stay

While complications weren’t higher, overnight admission was. The study found operative time was a consistent predictor of needing to stay overnight:

• • Each additional hour of surgery increased the odds of overnight admission by 64% (adjusted odds ratio 1.64; 95% CI 1.30–2.06).

What this may mean for you: If your surgeon anticipates a long case, it may be wise to plan emotionally and logistically for the possibility that you won’t go home the same day—even if everything goes smoothly.

Why “thoroughness over speed” matters in complex endometriosis surgery

The authors emphasize a clinical priority that many endometriosis patients value: doing the surgery carefully and comprehensively, even if it takes longer. In advanced disease, rushing can be risky, and meticulous technique may be more important than a shorter operative time.

What to ask your surgeon (actionable checklist)

Because this study was done at a specialized center, it’s especially helpful to discuss how your own setting compares. Consider asking:

Experience and setting

• • “Do you/your team specialize in stage III–IV endometriosis surgery?” This is the most important question because anyone or any "team" can do a lot of relatively easy cases. That does not usually predict safety or success for complex anatomically distorted cases.
  • “Is this a high-volume center for complex endometriosis cases?” This has to be tightly tied to the first question. In many centers doing multiple easy cases per day is valued way too much and this does not make the surgeon an expert. So, "high volume" needs to be taken in context if comparing to others. For example, it would be almost impossible for a surgeon to perform 300 4-6 hour surgeries in any given year. But for easy multiple cases per day, it becomes feasible.

What a longer operative time means for my plan

• • “If my surgery runs long, how does that change my recovery plan?”
  • “What would make you recommend an overnight stay?”

Expectations and safety

• • “How do you monitor and manage complications during and after surgery?”
  • “What support services are available if my case is complex (multidisciplinary support)?”

Outcomes beyond the short term

• • This study did not assess long-term outcomes such as pain recurrence or fertility. You can ask:
  • “How will we track long-term symptom relief and other goals after surgery?”

Important cautions (how not to overapply these results)

This study includes some key limitations that matter for patients:

• • Setting matters: The findings came from a quaternary referral center where surgeries were performed mostly by highly experienced endometriosis specialists, and results may not generalize to lower-volume centers or less specialized teams.
  • Long-term outcomes weren’t studied: The research did not evaluate long-term issues such as chronic pain recurrence, fertility, or late complications, which could potentially be influenced by operative time.
  • Don’t assume longer is “better”: The authors caution against misreading the results as proof that longer surgeries reduce complications. The overall complication rate was relatively low, which may limit the ability to detect small risk differences.

Bottom line for patients

For minimally invasive surgery for stage III–IV endometriosis performed at a specialized, high-volume center, this study found that a longer operative time was not associated with more short-term postoperative complications. However, longer surgery did increase the likelihood of an overnight hospital admission, so planning ahead is wise.

If you’re facing surgery, the most helpful next step is often not focusing on the clock—but on the experience of your surgical team, the resources of the center, and a clear recovery plan tailored to your case.