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 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.
Can I keep working with endometriosis?
Yes—many people with endometriosis keep working, but it often requires a realistic plan around symptoms like pain, fatigue, brain fog, heavy bleeding, and unpredictable flares. Work becomes harder when endometriosis pain isn’t just “period pain,” but a complex, whole‑nervous‑system experience that can persist throughout the month and sometimes continues even after partial treatments. If your job performance is being affected, that’s not a personal failure—it’s a sign your symptoms need more targeted evaluation and a clearer strategy.
In our practice, we think about work in two parallel tracks: managing symptoms so you can function day to day, and treating the underlying disease when it’s driving ongoing inflammation, adhesions, or organ involvement. Depending on your situation, this may include a structured pain management approach (often multimodal) and, when appropriate, excision surgery planning based on a careful review of your history, imaging, and prior operative/pathology reports. If you’re wondering what’s realistic for you—whether that’s staying at work with accommodations, reducing hours temporarily, or planning time off for treatment—reach out to schedule a consultation so our team can review your records and help you map out next steps.
What questions should I ask an endometriosis specialist?
Come in focused on how your surgeon thinks and how your care will be mapped out. Helpful questions include: based on my symptoms and records, what diagnoses are you considering (endometriosis, adenomyosis, and common look‑alikes), and what makes you lean one way or another? Ask what additional records or imaging would meaningfully change the plan, and whether your imaging will be interpreted with endometriosis mapping in mind—not just a “normal/abnormal” read.
If surgery is on the table, ask for specifics about technique and scope: do you primarily perform excision (rather than superficial burning/ablation), and how do you confirm what was removed (photos, operative report detail, pathology)? Ask what areas you expect could be involved in your case (ovaries, bowel, bladder/ureters, diaphragm) and whether a multidisciplinary team is planned if those organs may be affected. It’s also reasonable to ask how they define surgical “success” for your goals—pain relief, bowel/bladder function, fertility—and how outcomes and recurrence/persistent symptoms are handled.
Finally, ask how the care process works from start to finish: what the pre‑op workup includes, what recovery typically looks like for the anticipated complexity, and how follow‑up is structured if symptoms don’t resolve fully. In our practice, we review records purposefully before meeting so the conversation is productive and realistic, and we’ll be direct about whether surgery seems likely to help or whether another path makes more sense. If you’d like, you can reach out to schedule a consultation and we’ll tell you exactly what to send first so we can make your visit worth your time.
How long does pelvic floor therapy take to help endometriosis?
Most patients don’t feel a dramatic change after one visit—pelvic floor therapy for endometriosis tends to build over time. When symptoms are being driven by pelvic floor overactivity, protective muscle guarding, and nerve sensitization, early sessions often focus on assessment, calming pain signaling, and learning strategies your body can tolerate. Many people notice the first meaningful shifts over several weeks as muscles start to relax and coordination improves, especially for pain with sex, bladder/bowel symptoms, and daily pelvic tension.
How long it takes overall depends on what’s keeping your pain “switched on”—active disease, adhesions, central sensitization, posture/movement compensations, or a mix. If endometriosis lesions are still a major pain generator, therapy can still help reduce pelvic floor spasm and improve function, but it may work best as part of a broader plan that also addresses the disease itself. In our practice, we often use pelvic floor therapy as a complement before and/or after excision (when indicated) to support recovery, improve comfort with exams or intimacy, and reduce the odds that muscle and nerve patterns keep pain going. If you’d like, our team can help you figure out whether pelvic floor dysfunction is a key driver of your symptoms and what a realistic therapy timeline could look like for you.
Is it normal to feel broken from endometriosis pain during sex?
Yes—what you’re describing is incredibly common, and it doesn’t mean you’re broken. Pain with sex (during, after, or specifically after orgasm) can be a direct symptom of endometriosis, and it can also be reinforced over time by pelvic floor guarding and the nervous system becoming more sensitive to pain signals. When your body learns to anticipate pain, it can change arousal, lubrication, and the sense of safety around intimacy, which can make the emotional impact feel just as heavy as the physical pain.
We also want you to know that sexual distress can linger even when other symptoms improve, because it’s not only about the lesions—it’s about inflammation, adhesions that restrict normal movement, muscle tension, and how long you’ve had to cope. The good news is that this is treatable in a comprehensive way: we focus on identifying and addressing the underlying pain drivers (including disease that may benefit from excision) while also supporting pelvic floor and nervous system recovery so sex can feel safe again. If this is affecting your relationship, confidence, or quality of life, reach out to schedule a consultation—our team can help you map out why it hurts and what a realistic path forward looks like.
Will painful sex from endometriosis ever improve?
Yes—sexual pain (dyspareunia) from endometriosis can improve, and for many patients it improves meaningfully when we treat the underlying disease rather than only masking symptoms. Painful sex is often driven by deep lesions and adhesions that create mechanical pain with penetration, especially when disease involves areas like the uterosacral ligaments, rectovaginal space, bowel, or bladder. When those pain generators are thoroughly excised, the “trigger” for intercourse pain is often reduced, and many people notice gradual improvement over the months after surgery as healing progresses.
That said, painful sex doesn’t always disappear immediately—even after excellent excision—because pain can become “wired in” through pelvic floor muscle guarding, nerve sensitization, and central sensitization over time. This is why we often pair disease-directed treatment with a broader plan that addresses the pelvic floor and the nervous system, so your body can relearn safety and comfort with touch and penetration. If sex has become something you dread, reach out to schedule a consultation with our team—we’ll help you sort out what’s likely driving your pain and what a realistic path to improvement looks like for your specific case.