© Center for Endometriosis Care/Ken Sinervo MD, MSc, FRCSC. All rights reserved. No reproduction permitted without written permission. Revised since original publication (2005) and current (as of 2023). No external funding was utilized in the creation of this material. The Center for Endometriosis Care neither endorses nor has affiliation with any resources cited herein. The following material is for informational purposes only and does not constitute medical advice.

Was My Surgery a Failure??
There is perhaps nothing more frustrating and disappointing than feeling like your ‘best-hope-for-relief-surgery’ didn’t work to bring drastic relief. It’s a tough conversation, but let’s dive in and review some points of this multifaceted, complex issue that may occur – even following excision in the hands of an endo specialist. To begin, however, know that nothing YOU have done has failed. Persistent pain is NOT your fault!

We must first acknowledge that skill of the surgeon does matter and may constitute, in part, true ‘failure’ - meaning persistent endometriosis is left behind. The disease may have been left for whatever various reason(s) – perhaps even intentionally in some cases, if it is in the interest of the patient’s health – and can continue to cause pain/symptoms…or, sometimes, the endometriosis was just inadequately excised. In still other cases, it was actually not excised at all, but superficially “removed” (burned) - pathology and operative reports can verify. It is critically important to discuss with your surgeon what exactly was done, and why.

In some very select cases, it may be prudent (based on the patient’s specific situation) for the surgeon to leave an area of disease intact because the risks far outweigh the benefits of removal in terms of potential surgical complications. This is uncommon, however, as generally speaking, all endometriosis can be safely and successfully excised from all areas.  Nonetheless, outcome is often operator-dependent.

So, what defines an ‘expert operator’?  While there is no magic number of procedures or hours required to be considered highly proficient (though “10,000 hours” proponent Malcolm Gladwell may disagree), it is universally accepted that several hundred surgical cases constitute a certain level of expertise. For example, a New England Journal of Medicine editorial by a physician and a health policy analyst noted that ‘surgeons must do at least 150 procedures to become adept at using the robotic system.’  At the CEC, our surgeons have treated over 13,000 patients with varying complexities of endometriosis, including among the highest number of bowel and thoracic cases. We perform more than 400 cases of endometriosis each year, and excision of endometriosis and advanced gynecologic surgery is all we do.

There is also a possibility that surgical ‘failure’ is not actually failure at all. Recurrence/persistence of actual endometriosis can and does occur, even after sharp and meticulous dissection in the most skilled of hands – yes, even ours. Interestingly, some data implies that true recurrence may even be higher in patients with lower stage disease vs. advanced stages. It has also long been noted that some disease in younger patients is more ‘aggressive’ with a ‘higher recurrence rate’ and may even be a ‘different form of endometriosis altogether.’ This does not imply lack of meticulous skill or excisional attempts on the part of the surgeon (who is, first and foremost, human, after all!) – but rather, can be attributed to the complex, insidious nature of this disease. Patient-centric care using all the tools in our armamentarium - of which excision is part - is critical and has helped many.

Refractory pain may also not even be related to endometriosis at all.  Secondary pain generators and gynepathologies in our own and similar center’s re-operative populations includes conditions ranging from adenomyosis, fibroids, non-endometrioma cysts or adhesions to interstitial cystitis/painful bladder syndrome, pudendal neuralgia, congenital defects, pelvic floor dysfunction, pelvic congestion syndrome, vulvodynia, infection, unrelated bowel disease or other co-existing disorders that may contribute to the patient’s post-excision pain. All of these can cause continuing symptoms that are not related to the actual endometriosis. Each needs to be accurately diagnosed and treated accordingly, which is why we utilize a multidisciplinary approach. To a hammer, everything looks like a nail…but not everything is actually endometriosis-related symptomology. Thus, we must be cautious in automatically assuming the disease itself is the cause of continuing pain without being thorough in investigation, up to and including re-operative intervention to diagnose and treat any pathology if necessary/appropriate when non-invasive measures fail.

To that end, a multidisciplinary approach such as we practice at the CEC (incorporating a treatment team including but not limited to ours [gynecologic endoscopy], colorectal, urology, PT, nutritionists, pain management and various others specific to the individual’s own case) is key to ensuring effective treatment and maximum outcome, as well as reducing risks to the patient.  If endometriosis is assumed – or confirmed at re-operation – it must be treated, along with any and all other pathology that may be found.

All things considered, the literature – and importantly, our own experiences across thousands of global patients, in every stage of disease – has long supported excision as the ‘gold standard of surgical intervention’ for endometriosis; indeed, complete excision is a fertility-sparing procedure which prevents persistent disease in many cases and relieves multiple sequelae e.g., painful sex, pelvic pain, infertility, etc.  In our specific population, we document actual endometriosis after complete excision around 15-20% of the time. We track our patients – some are even almost 30 years out – and maintain an internal database on post-excision follow-up including reoperation of our patients both by us and others. Similar centers do the same and reflect, in general, comparable rates. This is not to say no one will experience ongoing pain and even endometriosis persistence/recurrence after surgery. Hopefully, the patient will be able to work with their providers to find ongoing care and solutions to restore their quality of life.

If pain persists or recurs even after excision with a sub-specialist in the disease, it’s not your fault. Tell your doctor and afford them the opportunity of trying to continue to help you. If they are not receptive to continuing care – find one who will be. Remember…you don’t have to settle for inadequate care, no matter what – other options always exist. Ultimately, endometriosis facilitates a partnership between the patient and provider(s); educated decision-making should not only be encouraged, but required by all those treating patients.