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Endometriosis Excision Surgery

by Tamer Seckin, MD | Posted on May 15, 2020

Treating Endometriosis with Advanced Laparoscopic Excision Surgery

Excision of endometriosis is considered the “gold standard” for treatment and requires an expert with considerable ability and experience. Dr. Seckin, one of a handful of doctors worldwide who is expertly trained and highly successful in advanced laparoscopic excision surgery for endometriosis, is a pioneer in this field. He trained with Dr. Harry Reich, M.D., one of the most celebrated laparoscopic surgeons in the world. Dr. Reich is a pioneer in endoscopy and performed the very first laparoscopic hysterectomy surgery in 1989.

Laparoscopic surgery is the most advanced treatment for endometriosis because it offers permanent removal of the endometriomas and offers the greatest pain relief. This surgery includes the excision of the endometriomas and the scar tissue and adhesions. Laser surgery, often the first choice of many doctors today, is far less effective because it only burns off the top layer of endometrial tissue, allowing for the endometrioma and endometriosis to quickly grow back. Laparoscopic surgery for endometriosis is an effective, less invasive option, which provides maximum results for the total removal of all disease.

Laparoscopic surgery for endometriosis also allows Dr. Seckin and Dr. Goldstein to safely and successfully to remove the endometriosis from all areas with minimal risk of damage to underlying vital structures. Utilizing sharp dissection, they are able to thoroughly eradicate all forms of endometriosis, including DIE (Deep Infiltrating Endometriosis) and adhesions. Surgical excision of endometrial implants provides the best symptomatic relief and long-term results. The result is improved fertility, the reestablishment of normal pelvic anatomy, and the eradication of symptoms.

Excision can be performed with any surgical tool, depending on the surgeon’s preference. Dr. Seckin uses the da Vinci system with its 3-D high definition camera that allows for precise excision of endometriosis. His endometriosis surgery is performed using cold scissors and bipolar capillary bleed control to keep the tissue surface as smooth as possible.

endometriosis surgery, endometriosis excision surgery, What is Excision Surgery

Minimally Invasive Surgery

The term "minimally invasive surgery" is thrown around quite often in the field of reproductive surgery. As a patient, it is important to ensure that your surgeon is able to determine a form of treatment that is most effective for you, while also ensuring minimal invasion.

We believe that robotic surgery is never the right method to treat your endometriosis. Though it may be at the forefront of minimally invasive technological development, we consider robotic surgery for endometriosis to be the "the most maximally invasive" form of minimally invasive surgery. This is because it typically requires more incision sites that are larger in diameter than in normal excision surgery. There is also a larger rate of robotic error than with humans. In fact, in an article published in the Journal for Healthcare Quality (2011), researchers from John Hopkins University found that promotional materials on robotic surgery listed on hospital websites generally overstated the benefits of robotic surgery, ignored the associated risks, and may have been influenced by manufacturers. For these reasons, we strongly believe that hand-made incisions and excision surgery are the proper way to ensure our patients the minimally invasive surgery that they deserve.

minimally invasive surgery
Minimally invasive surgery

Complete Excision

Using our patented Aqua Blue Contrast (ABC) technique, we ensure that no endometriosis lesion goes undetected. To a surgeon's eye, this aqua blue contrast makes endometriosis "shine" like stars in the night sky. By administering ABC during surgery, we are able to clearly identify and thus excise all suspected endometriosis scar tissue.

One of the key aspects of surgically removing endometriosis that is often overlooked amongst surgeons is the need to remove endometriosis lesions in their entirety. When surgeons conduct procedures such as laser ablation (use of a laser beam) and fulguration (use of electricity to produce heat) in order to "destroy" these lesions, they are only removing the scar tissue at a superficial level, not the nodule. Endometriosis lesions usually extend far deeper than just the surface of the tissue and it is crucial that the nodule is removed at its root, and in its entirety, if the patient is truly going to experience a relief of symptoms.

Endometriosis Iceberg Theory

Dr. Seckin likes to think of endometriosis like an iceberg. The peak is above water, but the iceberg’s bulk remains submerged underwater. "Shaving" off the top of the iceberg would appear to leave behind a smooth surface. What actually occurs, however, is that the largest - and most dense - a portion of the iceberg has been left behind beneath the surface. This is analogous to the superficial removal of endometriosis implants through the techniques of ablation, vaporization, cauterization, or fulguration. The disease is left to thrive and symptoms will recur.

By contrast, with deep excision, the entire "iceberg" - the endometriosis nodule - is "cored" out, leaving behind no residual disease, conferring low reoperation rates, and resulting in a highly successful outcome for long-term, endometriosis-free relief. This is why we strongly believe there is no better method than deep excision surgery when it comes to fully removing endometriosis.

Seckin Deep Excision
The importance of "cold excision"

The importance of "cold excision"

We believe that “cold excision” is the best way to remove endometriosis lesions. We use “cold excision” to mean that no electricity or high energy is used in order to remove scar tissue. When a surgeon uses heat to remove or destroy lesions, such as ablation, fulguration, or even some excision surgeries, it raises the possibility of leaving behind burnt tissue, which will cause additional pain. A surgeon should always aim to give a patient their highest chance of symptom relief, and we believe that “cold excision” surgery is the best way to ensure this.

Acute Visualization Strategy

Aqua Blue Contrast (ABC) technique
Using our Aqua Blue Contrast (ABC) technique, we are able to easily identify endometriosis lesions.

As noted before, one of the key ways to spot endometriosis is through the angiogenesis and inflammatory process that takes place in the peritoneum. Your surgeon should have an understanding of these types of medical nuances in order to ensure that they can identify both atypical and typical endometriosis lesions. One way this can be done is through changing the color spectrum of the peritoneum by using hydro-floatation with contrast color and retroperitoneal distention. The surgeon can then visualize endometriosis lesions that otherwise would be undetectable by standard laparoscopic inspection. We accomplish this by using Seckin’s Aqua Blue Excision (SABE)™. Using our trademarked technique, we are able to identify all forms of endometriosis lesions visible to the naked eye, thus ensuring the excision of as many endometriosis lesions as possible.

Advanced Cases

Even in complicated cases of deep infiltrating endometriosis (DIE), excision surgery is the best treatment option when in the hands of a skilled surgeon.

In cases of advanced endometriosis, where pelvic architecture is deformed and organs are fused in various degrees of adhesions, excision surgery can be more difficult and complicated than most cancer surgeries. However, it is still very much possible when performed by an expert laparoscopic deep-excision surgeon, who is expected to perform the ultimate reconstructive task of meticulously and painstakingly debulking endo lesions to restore the pelvic anatomy. The skill of the excision surgeon is most important concerning the repair and reconstruction of organs where the deep infiltrative disease was removed. No surgeon should attempt endometriosis excision surgery if they have not mastered suturing techniques for bowel and bladder repair. The thin transparent lining that covers multiple organ surfaces of the rectum, sigmoid colon, ureters, bladder, ovaries, tubes, and the uterus is called the peritoneum. Because endometriosis primarily involves the pelvic peritoneum, the endometriosis excision surgeon must be comfortable operating on the superficial surfaces and deep layers of these non-reproductive organs. Not infrequently, the intraoperative discovery of deeply infiltrative endometriosis (DIE) lesions of the bowel, bladder, and ureter requires delicate repair of these organs and must be performed by an experienced and skillful endometriosis surgeon and his or her endometriosis team.

Organ Preservation

Many surgeons’ preferred method of surgical removal is through laser ablation or fulguration. Both of these methods look to "destroy" endometriosis whether by means of laser beam irradiation or heat produced by high-frequency electric currents. However, by conducting these types of destructive surgeries, the surgeon is not only not fully removing all endometriosis, but also jeopardizing the surrounding healthy tissue. In addition, by destroying the endometriosis scar tissue specimen, the surgeon loses the opportunity to formally confirm with pathology that the believed scar tissue does, in fact, contain endometrium tissue, thus confirming endometriosis. We believe that it is crucial to treat your body with the sensitivity and care it deserves, which includes providing our patients with a thorough and complete diagnosis along with treatment. Thus, our expertise in excision surgery coupled with our strong sense of teamwork with the pathology lab allows us to harmlessly remove all suspected endometriosis lesions as well as confirm a proper diagnosis.

Post-Op Outcomes

Recovery Period

A patient's recovery period after endometriosis excision surgery will vary. A woman who undergoes a three-hour surgery to have endometriosis removed from a small area will likely recover much more quickly than a woman who has an eight-hour surgery to remove lesions from several organs. Our goal with every patient is to have them out of the hospital within twenty-four hours. We believe that it is better for patients to be moving around and getting their strength back in their home rather than in the hospital.

Symptom Relief

We never promise a patient that her pain will be reduced to a specific level; no doctor can guarantee a precise result with any treatment. We don't perform miracles, and there is no magic here. We cannot control a woman's pain. But we can promise our patients that we will remove each adhesion and as much endometriosis as we possibly can, while not removing any organs unless it is absolutely necessary.

Recurring Symptoms

There are some rare instances where a patient's symptoms resurface. We videotape all our surgeries so that they can be reviewed by your surgeon if needed. This is especially helpful if a patient's pain comes back. Your surgeon will review this videotape step-by-step with their team to discern why you may still be experiencing pain. We always do our best to ensure that patients receive the individual care and treatment that their body needs.

We pride ourselves on having a low rate of patients with symptom recurrence. We work tirelessly from the very first time you walk into our office to fully understand your case. However, no one knows your symptoms better than you. By opening up the doors of communication, patient to a surgeon, we are able to come up with a proper diagnosis and treatment plan in order to ensure you have the highest chance of symptom relief. We cannot tell you how many patients come to us after having multiple surgeries elsewhere, only to have minimal symptom relief. We want to work with you in order to ensure Seckin MD is your final stop in the path towards endometriosis pain management, and the first step is through effective communication.

Are there non-surgical ways to treat endometriosis?

Primary care physicians will often prescribe medication as a form of conservative treatment for endometriosis before referring patients to a referral center. Some patients find relief with medication, while others do not. It is truly a case-by-case basis. Nevertheless, these drugs usually only provide patients with temporary symptom relief at best. But they can be useful when taken following a thorough and successful excision surgery in order to ensure full relief of symptoms, with low risk of return. Thus the following medications and methods should be seen as additional treatment options that can be utilized for pre or post-surgery, as opposed to substitutes for surgical treatment for endometriosis.

  • Pain medication: Painkillers are drugs that are supposed to "kill the pain." They are most often the option that many doctors and patients elect to try first to provide temporary relief. Nonsteroid anti-inflammatory drugs such as ibuprofen are the most common. Narcotics can also be prescribed in more severe endometriosis surgery cases, but these bring the risk of dependency and addiction and are subsequently not recommended especially if the patient finds that the narcotics have no effect, their pain has gone away, their side effects are worse than their symptoms, or they need to take a higher dosage.
  • Progesterone antagonist (hormone therapy): Progesterone, a hormone released from the ovaries, has changing levels that dictate menstrual periods. Because a high rate of retrograde menstruation is one of the believed primary causes of endometriosis, controlling this process through progesterone agonist drugs can be very useful, especially in cases of fibroids. These hormones can be taken via oral medication, injection, or even as an intrauterine device (IUD) such as the Mirena coil.
    Mirena coil, IUD, progesterone antagonist or hormone therapy
    The Mirena coil is an IUD that can serve as a progesterone antagonist or hormone therapy that ultimately can help reduce endometriosis symptoms.
  • Birth control: Birth control pills, most of which contain the hormones estrogen and progestin, prevent a woman's ovaries from performing ovulation. Taking these pills can reduce the heavy bleeding that an endometriosis patient may experience during her period. This will also decrease retrograde menstruation, a probable cause of endometriosis.
  • Nutrition: Like medication, a diet that works well for one patient may not for another. If your body is telling you that it doesn't want a certain food, you would be smart to remove that food from your diet. Generally, endometriosis patients should consider cutting out inflammatory foods such as white sugar, dairy products, common cooking oils, trans fats, deep-fried foods, processed foods, red meat, alcohol, and wheat. Instead, antioxidants (berries, pineapple, etc.) and organic foods are advised.
  • Acupuncture: Acupuncture is a system of medicine based on energy flow concepts and the body’s need to maintain homeostasis (physiological balance). Pain caused by endometriosis produces an imbalance in the body, and while we are in no way stating that this method can rid the patient of suspected disease, acupuncture can be useful to relieve symptoms. In fact, controlling associated pelvic pain and infertility through this method has been proven to be effective by several scientific studies.
  • Freezing eggs: Women often discover they have endometriosis when they attempt to conceive children. For women looking to have children at some point in their life, it can be very useful for them to freeze their eggs early if they have a family history of endometriosis or are concerned about fertility.

Drug Therapy & Endometriosis

Unfortunately, women and girls are often left to "manage" endometriosis discomfort with powerful painkillers and hormones, both of which merely mask the disease. These patients are often misled to believe that by suppressing the symptoms they are treating the disease. This generally results in the disease progressing—the symptoms become worse and no longer respond to medication. It is true that drug therapy can offer some relief for symptoms of endometriosis, but it does not help correct the underlying problem. Drug and hormone therapy has consequently caused many women a long delay in effective diagnosis and treatment. This has led to many "hit or miss" surgeries with high recurrence rates and, sadly, thousands of unnecessary hysterectomies. The definitive treatment of endometriosis is NOT hysterectomy or ovary removal, but instead the complete excision of the disease.


Why is it excision surgery favored over other forms of surgery?

Endometriosis excision surgery is recommended over other surgical methods due to their destructive nature. These techniques, namely laser ablation and electrical fulguration, are ineffective because they don’t remove all of the endometriosis. With these surgeries, most patients have their pain return in less than a year. More importantly, these methods do not allow confirmation of visual diagnosis by a pathologist because the tissue is not actually removed, but destroyed. What makes excision surgery the most effective way to treat endometriosis is that it doesn’t zap out the tip of the disease, as laser surgery does. It doesn’t burn the tissue either. Rather, it removes the inflammatory tissue by its root. In addition, the surgeon not only removes diseased and damaged tissue but also skillfully reconstructs organs and restores their functionality.

Is deep excision surgery common?

At this time, only a handful of doctors perform this type of surgery. Learning and refining the procedure requires extreme experience, knowledge, time, precision, dexterity, and patience. And expertise in performing endometriosis surgery cannot be defined without the ability to treat unintended consequences and complications. It is also imperative that every endometriosis surgeon has the precise skills to suture and tie tissues and to return an organ to precisely where it should be. The organs must also function well after surgery. In sum, the skills required include not only the technique but also meticulous bleeding control, suture repair, and reconstruction, and restoration of organs. Because of the great expertise that is required, few surgeons are capable of performing deep excision surgery. Nevertheless, it is still the most successful form of endometriosis surgery and should be sought out by patients looking for the highest chance of symptom relief.

What is the difference between excision and resection surgery?

Resection surgery is the removal of diseased tissue, but the procedure does not confirm that all diseased tissue has been removed. Excision surgery, on the other hand, ensures the complete, border-free (i.e. not leaving anything behind) removal of scar tissue. This phrase, “border-free removal,” is important to take note of, as resection surgeries often do not ensure the complete removal of diseased lesions because they cannot guarantee that the diseased tissue has not spread to the surrounding borders. This is one of the primary reasons it is so important to find a surgeon who can ensure complete surgery and not just resection surgery.

How is pathology used in this type of surgery?

One of the most critical aspects unique to deep excision surgery is the confirmation of an endometriosis diagnosis by a pathologist. Unlike other forms of endometriosis surgery, this surgery preserves the removed scar tissue so that it can be given to a pathologist, who views the sample under microscope magnification. The pathologist reports the extent of inflammatory changes caused by endometriosis including border-free status (i.e. whether anything was left behind), and also rules out whether there are cancerous changes of the endometriosis cells. The detailed description of where these are taken from, their size, and the number of specimens removed may reveal the tenacity and skill of the surgeon. The pathology review is an important point about the quality of surgery verifying the completeness of the procedure.

What does "laparoscopic surgery" mean?

Laparoscopy enables a surgeon to visualize the abdominal/pelvic cavity using an instrument known as a laparoscope. A laparoscope is a long, thin tube with a telescopic lens, multiple light sources, and a miniature video camera. This device is inserted into the abdomen and pelvic cavity through 3-4 small incisions. The video from this device is projected onto a large monitor set-up on the other side of the operating table so the surgeon is able to see a clear image of the abdomen and pelvis while they operate on the patient.

What makes excision surgery so successful?

A recent study from Sweden suggests that patients with endometriosis who were treated with excision surgery had a reduced incidence of ovarian cancer compared with endometriosis patients who did not have excision surgery. Similarly, controlled studies have proven that, compared to other surgeries, excision surgery offers the best outcome for pain relief and a positive impact on the quality of life. Whether treating something as significant as the frozen pelvis or as small as a single peritoneal lesion, the gold standard is to excise the disease without leaving any endometriosis behind. What is being excised is the inflammatory tissue of the peritoneum with its peripheral and deep scarring extending to small nerves and capillaries. Additionally, only the excision technique can address the treatment for all symptoms of endometriosis, including dysmenorrhea (painful periods), dyspareunia (painful sexual intercourse), dyschezia (painful bowel movements), and leg and back pain with menstruation.

So, can surgeons treat and "cure" my endometriosis?

This is a great question for clarification purposes. While there is no cure for endometriosis, there are treatment options that can help to relieve symptoms that many patients report has drastically improved their quality of life. After receiving the proper surgical treatment for their particular case, many patients have found relief from symptoms such as painful periods, GI abnormalities, painful sex, painful bowel movements, and even in some cases, infertility. Nevertheless, endometriosis treatment is a field that still requires a great deal of research, which is why there is never a sure guarantee of symptom relief when treating endometriosis.

What else should I look for in a specialist?

In order for an endometriosis excision surgeon to utilize their skills for treatment, they must first be familiar with all appearances of endometriosis. Typical lesions are quickly visualized with varying colors from red to black, but they are always outnumbered by atypical and microscopic endometriosis, which is not easily recognized. The inexperienced surgeons who do not practice endometriosis excision surgery may miss these occult and deep lesions. The angiogenesis and inflammatory process that is also taking place in the peritoneum must be recognized in addition to the typical and atypical lesions of endometriosis.

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (212) 988-1444 or have your case reviewed by clicking here.


  1. Hospitals Misleading Patients About Benefits Of Robotic Surgery, Study Suggests
  2. What Is Laparoscopic Surgery? WebMD

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Medically reviewed by Tamer Seckin, MD on May 15, 2020

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