Excision surgery
Every lesion removed at full depth with margins, including bowel, bladder, ureters and diaphragm.
Excision means cutting the disease out at its full depth, rather than burning its surface. It is technically harder and it takes longer, which is why we schedule fewer cases in a day than centers that ablate. It is also why our patients are less likely to need a second operation.
What excision actually involves
Excision means cutting the disease out at its full depth and taking a clear margin around it, which is the same principle a cancer surgeon works to. We remove the tissue rather than burning its surface.
That sounds obvious, and it is: if there is something in the body that shouldn't be there, you take it out. The difficulty is that endometriosis is a microscopic disease. When we look inside, what we can see is the injury it leaves behind rather than the disease itself: scarring, blistering, blood vessels growing where they shouldn't.
In training, surgeons were taught to look for three things: blisters, ovarian cysts, and the classic black "powder burn" marks. The disease actually has around twenty different appearances, and a lot of them are subtle. So we look for everything that is abnormal, and we take all of it, with a margin.
Why not ablation?
Ablation was the standard of care, and it is what I was taught coming through training. You look inside, you find something that looks like endometriosis, and you burn it. The reasoning was that if living tissue is irritating and injuring things, killing it should stop that.
It never worked very well. Published pathology data shows that burning a lesion destroys perhaps the top 50 to 60 percent of it. The rest stays underneath and carries on causing the same irritation and injury. The outcome data followed: around 90 percent of patients had symptoms return within a year, and around 60 percent had another operation within a year.
It helped some people, at least for a while. It is also why patients arrive here with twelve, thirteen, fourteen previous operations behind them, none of which quite worked.
What the results actually look like
Published data for excision done well puts disease clearance at around 95 percent, with a long-term reoperation rate of about 10 percent.
That is not perfect, and we don't claim it is. Five percent is still five percent. But it is a different profile from what came before it, and it is enough to make a lasting difference to how people feel.
I hope that ten years from now we are considerably better than we are today. We are quite a bit better than we were.
Where this technique comes from
Excision was pioneered by Dr. David Redwine, the first surgeon to perform it. Much of the long-term outcome data quoted above comes from his work and his publications, so this is a technique with decades of follow-up behind it rather than a new idea being tried out.
Surgical lineage counts for a great deal here, because this technique is taught hand to hand rather than learned from a paper. Dr. Redwine showed it to Dr. Mackenzie, now retired. Dr. Mackenzie taught me, and taught Dr. Awosogba.
That has a practical consequence as well as a historical one: it is why the two of us operate the same way. When we say you get the same operation whichever of us you see, it is because we were taught it by the same surgeon, in the same tradition, going back to the person who invented it.
Boston Endometriosis Care is a young practice, but this surgery is not new to us. Before this we operated as part of a larger group doing exactly this work, with the same technique and often the same operating rooms, refining it by learning from each other over years. That shared history is where the four thousand figure comes from.
Surgeons trained in this lineage now practice elsewhere in Massachusetts and in New York, and teaching the technique properly, rather than keeping it, is deliberately part of what this practice is for. There are not enough excision surgeons, and training more of them is how that changes.
What if the disease is on my bowel or bladder?
First, something that surprises most people: bowel and bladder symptoms are more common in endometriosis than pain is. Everyone focuses on pain, and pain matters. But difficulty going to the bathroom, difficulty eating and drinking, and urinary urgency are all more common, and patients frequently find them worse.
We have cared for patients whose main symptom was never pain at all. Needing a bathroom every ten or fifteen minutes will end a career and a social life just as thoroughly. You cannot hold down a job or go out with friends when every outing has to be planned around the next bathroom.
So yes, we see disease near the bowel and the bladder every day. In the large majority of cases it is sitting on the surface and irritating it, and the work is to separate it away carefully. Sometimes it extends a little into the surface and we stitch that closed.
A small number of patients have disease that genuinely invades the bowel or bladder and needs a resection. We work with colorectal surgeons, urologists, and vascular and thoracic surgeons on those cases. That is planned in advance, through careful history, examination and imaging, rather than discovered on the day of surgery. We would rather have no surprises in the operating room.
Who should not have this operation
Having endometriosis is not, by itself, a reason to operate. The decision rests on how you are feeling and how you are doing.
We have plenty of patients with an endometrioma on a scan, or endometriosis noted during a previous operation, who feel well. They do not need us to do anything, and we can leave them in peace.
We operate when the disease is getting in the way of the life you want. For some patients that is completely disabling. For others it stops them exercising, or damages a physical relationship, or stands between them and a pregnancy. The scale varies enormously and it is not for us to rank it. If endometriosis is preventing your life from being what you want it to be, that is the reason to treat it.
Even if the answer today is that you don't need surgery, the consult is still worth having. You leave with an explanation and a plan, and with someone to come back to if things change.
The thing patients are most afraid of
It isn't the operation. Overwhelmingly, patients are frightened that we will look inside and find nothing.
That fear was put there by other people. Patients are told that a laparoscopy is the only way to know whether endometriosis is there, and, far more damagingly, they have spent ten, twenty, thirty years being told their symptoms are normal and they should get on with it. It reaches a point where they doubt themselves. What if I'm imagining it? What if I just tolerate pain less well than everybody else?
In practice, a careful history reaches the diagnosis. Asked the right questions, patients tell us where the disease is as well as that it is there: which nerve is involved, which segment of bowel it sits against. We plan the operation around that.
Counting every surgeon trained in this lineage, including those who have since retired or moved to other practices, we have performed well over four thousand of these operations. Not once have we scheduled an operation for endometriosis and then failed to find it. Sometimes we find more than we expected and the operation becomes bigger than planned. We have never gone in and found nothing.
We photograph what we find. At your post-operative visit we go through those photographs in detail, so you can see in three dimensions where the disease was and what it was doing.
The first thing patients say when we tell them what we found is almost always the same: so I'm not crazy. It wasn't all in my head. Fixing things surgically is one part of this job. Being believed, and then being shown the physical proof of what you had been describing all along, matters at least as much.
Why you go home the same day
Most patients go home the same day, and that includes hysterectomy. That is a clinical decision rather than a financial one.
Surgery used to keep people in for days or weeks. The evidence now runs strongly the other way: patients discharged the same day recover faster, are up and moving sooner, have better pain control, and have fewer emergency department visits and fewer complications. Asked six months later, they report a better recovery than those who stayed in.
A hospital has alarms going off, staff checking vital signs every few hours through the night, and a bed nobody sleeps well in, none of which helps you recover. If your pain or nausea can't be controlled we will of course admit you, but where we can get you home, we will.
How long until I'm back to normal?
On average, about two and a half to three weeks before you feel like yourself again.
Day one. You are home, and you are up and walking, slowly but walking.
The first three or four days. Most people need pain medication for around this long, then come off it.
Weeks two and three. This is the part nobody warns you about: muscle spasm. It appears around the areas we operated on, and in places where you already had spasm because the muscles had been irritated by endometriosis for years beforehand. It is a normal part of recovery and it is treatable, and it is one of the things we look for at your follow-up.
Around two and a half to three weeks. Most people feel like themselves. For much of that time you are not taking pain medication at all, just a little tired and a little sore.
If you have had a hysterectomy as well, add roughly another week of feeling wiped out.
The variation is real, and it depends almost entirely on where you are starting from. Some patients arrive with muscle spasm so severe they cannot walk and are using a wheelchair; we know in advance that the second half of their recovery will take longer and need more work. Patients who have no muscle spasm to begin with sometimes go back to work, or to sports, inside a week.
We ask for four weeks on your FMLA paperwork so the room is there if you need it. Going back sooner than that is entirely fine.
Recovery is more than the incisions healing. Muscle spasm frequently needs treating, and adenomyosis may need addressing separately. The psychological part of it, being recognized and understood and shown the evidence, is a real component of getting better.
What it costs
Our professional fee is avg $8,500. Varies ($7,500–$10,500 max) by surgical complexity. The facility bills your insurance separately for hospital care, anesthesia, labs and imaging. Full fee detail →