Minimally Invasive Surgery for Endometriosis Treatment: A Specialist’s Perspective

Endometriosis is a highly complex condition that can’t be easily solved. “It’s like having a chronic illness, such as diabetes — it’s something that patients unfortunately often deal with for most of their reproductive lives,” says Dr. Roa Alammari, a provider at Mansfield Ob/Gyn Associates, a Women’s Health Connecticut practice. Where does surgery fit into the treatment equation? Dr. Alammari is an expert on the subject; after medical school and residency, she completed a fellowship in minimally invasive gynecologic surgery at Beth Israel Deaconess in Boston, focusing on the laparoscopic treatment of advanced endometriosis and complex fibroids.

With rising awareness around endometriosis and more women looking for answers not only on managing their condition, but also on finding viable treatment options, we sat down with Dr. Alammari to talk about her specialty in minimally invasive gynecologic surgery and the management of endometriosis, uterine fibroids, benign ovarian masses, and other conditions.

Key Takeaways

• Excision surgery produces better endometriosis outcomes than fulguration, the “burning” technique — because fulguration is superficial and can leave implants behind, Dr. Roa Alammari advises choosing a surgeon trained in advanced excision, since the quality of the first surgery determines how long remission lasts and how many operations a patient ultimately needs.
• Surgery is an adjunct to medical therapy for endometriosis, not a replacement cure — Dr. Alammari treats the condition as chronic, meaning patients rely on hormonal suppression across their reproductive lives even after surgery, because some disease is always left behind.
• Endometriosis symptoms can begin as early as age 12 or 13, and severe period pain causing missed school days strongly suggests the disease — recognizing this pattern early counters the diagnostic delay that the condition’s non-specific symptoms typically create.
• Imaging alone usually cannot detect endometriosis, so laparoscopic surgery is often required for confirmation — ultrasound identifies ovarian endometriomas, and MRI reveals deep infiltrating nodules, but much of the disease is visible only during surgery, and some remains invisible entirely.
• Patients with unresolved pelvic or menstrual pain should name endometriosis directly to their ObGyn and seek referral to an experienced minimally invasive pelvic surgeon — self-advocacy, a second opinion, and tools like the AAGL Physician Finder lead to earlier, more effective treatment.

Why Endometriosis Remains Underdiagnosed

Women are becoming more aware of endometriosis, but they’re still going months to years without an accurate diagnosis. Even the latest data shows that women report a delay of up to 10 years between the onset of symptoms and a diagnosis.

There are several reasons for that delay. Endo’s hallmark symptoms — painful periods and pain during intercourse, sometimes with painful bowel movements or urination are sometimes indistinguishable from other conditions. 

Additionally, symptoms can start remarkably early, and younger patients may not even fully understand what they’re experiencing. Dr. Alammari notes, “Usually, the patient can have symptoms within her first few periods, as early as age 12 or 13.”  The earliest endometriosis symptoms are usually painful periods, so if your child has severe period pain that causes them to miss school, that’s highly suggestive of the disease. Recognizing that pattern early is one of the few things that shortens the diagnostic delay.

Why Isn’t Imaging Enough For a Diagnosis?

Yes, an ultrasound can catch ovarian endometriomas, and MRI can reveal deep infiltrating nodules, but imaging alone isn’t enough for a confirmation. Laparoscopic surgery can confirm the severity of endometrial lesions and help your provider make the best treatment decision for your unique situation. Even in the operating room, Dr. Alammari explains, surgeons can easily spot the appearance of typical implants, but the atypical variety can be more challenging, which is where an examination of peritoneal surfaces comes in.

Endometriosis Treatment 

For most patients, treatment begins with medication, not surgery. “We would usually start with hormonal treatment, such as birth control for initial treatment,” counsels Dr. Alammari. Hormonal options — pills, vaginal rings, Depo Provera, Nexplanon, and hormonal IUDs — suppress the disease and control pain. Dr. Alammari recommends combining those with pelvic physical therapy as a first-line treatment.

When those aren’t enough, the range of endometriosis treatment options widens:

• Anti-inflammatories to blunt the prostaglandins, a lipid that can mediate pain by activating an inflammatory response.
• Gabapentin, an anticonvulsant that is often used to treat endometriosis pain by its effect on neuropathic pain.
• GnRH agonists like Lupron Depot (leuprolide acetate), which induce a temporary medical menopause but are limited to about six months of use because of their effect on bone density. 

There are also emerging therapeutic options — aromatase inhibitors, which block the enzyme endometriosis uses to make its own estrogen, and elagolix, a GnRH blocker that similarly starves the disease of hormonal support.

Endometriosis Surgery 

Your provider will provide the best counsel on when Surgery for endometriosis is the best route. Dr. Alammari cautions patients against thinking of surgery as one-and-done. Surgery, she says, “is not an alternative to medical therapy; it is an adjunct.” Surgery can leave behind residual lesions, so providers recommend hormonal suppression to sustain the benefits of the surgical procedure.

How Laparoscopic Surgery for Endometriosis Works

There are two options for endometriosis surgery: excision, which is physically cutting the disease out, or ablation, a procedure that uses energy to burn the implants. Dr. Alammari warns that the two are not equivalent. Endometrial ablation is an in-office procedure recommended to women with abnormally heavy periods, but may not be the best option for endometriosis. 

Excision often leads to better outcomes for those patients: “The quality of the first surgery is important to achieve longer intervals of disease remission and decrease the number of surgical procedures needed per patient,” says Dr. Alammari. Her practical advice? Look for an experienced surgeon able to provide more than one option, including advanced excision if necessary.

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What to expect from endometriosis surgery recovery 

Because most of Dr. Alammari’s procedures are performed with a minimally invasive, laparoscopic approach rather than open surgery, recovery is generally shorter than many patients expect. Below is a quick overview of what to expect after endometriosis laparoscopy surgery:

• Recovery is much faster than traditional surgery, but it still varies: The extent of disease and whether bowel or bladder work was involved affect the timeline — some feel recovered in a few weeks, others need longer after more extensive surgery.
• Recovery happens in stages: External healing is relatively speedy, but internal pelvic recovery takes longer. Typically, the first 3 days you should focus on nausea and pain management, then focus on incision care weeks 1-3, and finally gradually resume daily activity weeks 3-6.
• The first 72 hours are the roughest: Most patients experience peak symptoms in the first 48 hours, including grogginess from anesthesia, bloating, and incision soreness.
• Most patients go home the same day: Others will go home after a short overnight stay, depending on the type nd extent of the surgery.
• You can gradually reintroduce activity: Short walks early on, gentle core and stretching in weeks 3–6, and no heavy lifting or high-impact exercise until cleared by your provider, often around the 6-week mark.

Risks for minimally invasive surgery are less, but there’s still a chance for issues during recovery. Contact your care team for a fever above 100.4°F, spreading redness or pus at an incision, heavy bleeding, worsening pain, or an inability to urinate or pass stool.

Can Endometriosis Come Back After Surgery?

Yes, even after excision, endometrial lesions can return. Endometriosis is a chronic condition, and some implants are microscopic or invisible during surgery; residual disease can remain, and symptoms can return. This is exactly why Dr. Alammari recommends continuing hormonal intervention even after a successful surgery: “Any residual disease that may be left behind will be controlled with hormonal suppression.”

Frequently Asked Questions

Can endometriosis come back after surgery?
Yes. Because some implants are microscopic or invisible during surgery, residual disease can remain, and symptoms can return. This is why Dr. Alammari treats surgery as an adjunct to medical therapy rather than a cure — hormonal suppression after an operation is what controls any disease left behind.

What’s the difference between excision and fulguration (ablation)?
Excision cuts the disease out; fulguration burns it with energy. Fulguration tends to be more superficial, while excision is associated with better outcomes. However, both can leave residual implants.

Can my provider diagnose endometriosis with imaging?
Usually not on its own. Ultrasound can identify ovarian endometriomas, and MRI can reveal deep infiltrating nodules, but much of the disease doesn’t show up on a scan — so confirming it often requires laparoscopic surgery.

Does a hysterectomy cure endometriosis?
Not reliably. Dr. Alammari considers hysterectomy a last resort after other treatments have failed, and notes the disease can recur even without the uterus. Unless there’s another condition like adenomyosis, it isn’t an appropriate standalone treatment — and endometriosis can usually be managed without removing the ovaries.

At what age can endometriosis start?
Symptoms can begin within a patient’s first few periods, as early as age 12 or 13. Severe period pain that causes missed school days is highly suggestive of the disease and worth raising with an ObGyn.

When is surgery recommended over medication?
Surgery becomes an option when one or two hormonal treatments fail to control symptoms, or when a patient wants to conceive, and hormones aren’t suitable. It’s used both to confirm the diagnosis and to reduce the burden of disease, so medical therapy works better afterward.

Advice for Patients Who Feel Unheard

Dr. Alammari empathizes with patients who feel dismissed, and her closing counsel centers self-advocacy. Patients with unresolved menstrual and pelvic pain should raise the possibility of endometriosis directly with their ObGyn and seek a second opinion if their symptoms aren’t taken seriously — naming the condition helps get it onto the differential and speeds treatment. If complex surgery is more likely, she encourages patients to ask candidly about their provider’s comfort operating on advanced endometriosis and to seek referral to an experienced pelvic surgeon.

If you’re weighing endometriosis treatment and want to understand which options fit your situation, a conversation with a Women’s Health Connecticut provider is the place to start. Make an appointment today so we can provide the best support and counsel for relief and treatment.