Excision clearly means the complete removal of endometriosis. Ablation depends very much on the surgeon as well as the condition of the implant or tumor. In many cases small parts of endometriosis might be left behind so that a recurrence has to be taken into consideration.

Because endometriosis can involve various structures, with varying degrees of infiltration, surgery is considered as one of the most challenging surgeries in gynaecology. It is one that not many surgeons are doing. With this in mind, what is the purpose of surgery in endometriosis?

Unfortunately, medical therapy for endometriosis including endometriosis associated pain is only symptomatic and does not remove the endometriosis implants. Therefore, surgery is still in many cases the only way to help stop the suffering of affected women.

One of the biggest controversies is ablations vs excision. Some doctors claim that both procedures are pretty much the same. From a surgical point of view, what is ablation and what is excision?

Excision clearly means the complete removal of endometriosis. Ablation depends very much on the surgeon as well as the condition of the implant or tumor. In many cases small parts of endometriosis might be left behind so that a recurrence has to be taken in consideration.

We know that excision is used in cancer, whereby a piece of tissue with margins is removed in order to fully remove the disease. In endometriosis, how is excision executed? Do we have a margin as well?

Since fortunately endometriosis is not a malignant disease it is not necessary to have a safety margin. However, in a lot of cases endometriosis has no clear circumference and might even infiltrate the surrounding healthy tissue so that a wide excision is advised

What is the youngest and the oldest patient that you have operated on?

The youngest patient was a young girl of 16 years with a family history of endometriosis where her mother knew from the beginning of hearing her daughter complain of severe menstrual pain that this could be endometriosis.

The oldest patient was clearly postmenopausal perhaps in her late 50ies or early 60ies. She had endometriosis before which was not completely removed and as she knew the symptoms came for final surgery.

Gateway Clinics GmbH, Amelia-Mary-Earhart Straße 17, Frankfurt am Main, Germany
Photo source: courtesy of NSSU

Studies and patients’ experience show excision to be the best method for improving symptoms on a long term. However, this depends on if all visible or palpable diseases have been excised. In some cases, results may not be permanent, and endometriosis may return. So, what is the principle of excision? Is it to avoid organ damages, or to save reproductive organs? Is it to remove the source of the pain?

Probably the most important reasons or indications for endometriosis surgery is to remove the source of pain as this is sometimes debilitating for the women affected. Also, vital structures in the pelvis need to be protected from being damaged by endometriosis as for instance endometriosis can strangulate the ureter and thereby cause severe kidney problems including insufficiency of the kidney. Of course, in those women that had not completed their family planning surgery might involve a compromise as maintenance of reproductive organs is of utmost importance.

In endometriosis some say there is no cure, others say excision is the cure. When surgery is done and all the disease is removed, is that person cured, even if it might be temporary? Or only if they have no more symptoms?

As menstruation is in most cases the reason for endometriosis a woman in her reproductive age that wants to become pregnant and therefore menstruates regularly might have a stimulus for recurrence of endometriosis with every menstruation even though the excision has been complete. So in principle, the disease was cured but due to a normal condition (i.e. menstruation) it was reignited.

In some cases, despite surgery being executed correctly, patients have little or no improvements. What can be the cause, or what explanation do we have in this case?

This is the most difficult question as it might be that the initial diagnosis was not correct, and the pain should be linked to other reasons than endometriosis. There are many differential diagnoses including psychological causes like post-traumatic disorders. Therefore, pre-surgical diagnosis must be executed very carefully as it is not easy.

Given your experience, in patients that had 10 or more surgeries, and they are still in pain, will another surgery help them, or it won’t bring them much improvement?

This very much depends! Unfortunately, we see patients that had multiple incompetent surgeries where the disease was only removed superficially. In those cases, a thorough diagnosis with excellent imaging and precise pain mapping following the description of the patient is absolutely mandatory in order to decide whether the patient will benefit from another surgery.

Despite having surgery done correctly, or in some cases, by the same doctor, results are different. Some patients have a higher symptom improvement, and others far less. What can be the reason?

First of all: pain is quite subjective which might already explain the differences. In addition, especially in case of several previous surgeries side effects of these operations might be the reason for continuous pain or discomfort.

We know that excision is a procedure that requires high knowledge of pelvic anatomy and high level of surgical skills in order to remove the disease in a safe and efficient way. From this point of view is ablation easier and why is it inefficient in endometriosis?

Endometriosis is a disease that involves several disciplines in addition to gynaecology. Particularly in deep-infiltrating-endometriosis it is best if the surgeon is experienced in gynecology, bowel surgery as well as in urology. If the surgeon shies away from operating in a different disciplines area than his or her own than incomplete removal of the diseased tissue is very common as we see in many cases of ablation.

The pelvis has anatomical danger zones where there is a risk of damaging underlying structures. When it comes to ablation, they say that it can be used in said zones due to damaging organs, hence why excision is better. What are the basic surgical principles employed in excision in order to fully remove the disease and avoid damage to these organs?

As mentioned above excision means the complete removal of the disease. Even if endometriosis is close or involving important and vital structures or organs excision needs to be performed in order to prevent further destruction of that particular region. This might involve that e.g. autonomous nerves can be destroyed causing bladder dysfunction. In ideal cases the pre-operative diagnosis is so precise that this instance can be suspected and needs to be discussed with the patient. Then it will be her decision whether the unhealthy tissue should be completely removed, or parts should be left behind possibly causing recurrence of the disease already after a short interval. I think it is only fair to the patient to explain not only the procedure but also the limitations of surgery.

Do we have limitations in excision? Meaning are any types of cases where excision can’t be used?

If family planning is a vital issue removal of endometriosis of any reproductive organ has to be performed extremely carefully meaning that sometimes endometriotic tissue has to be left behind. For example, ovarian endometriosis has to obey the ovarian reserve so that production of oocytes is still possible. Another example might be brain endometriosis (which fortunately is quite rare) where the surrounding tissue needs to be protected from radical surgery. In bladder endometriosis implants close to the trigon (i.e. where the ureters end in the bladder) must carefully be respected as otherwise innervation of the bladder might be compromised or even the function of the ureter could be impaired.

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Robotic surgery is definitely on the rise especially for complex surgical tasks. It is important to understand that a robotic console is just a surgical instrument in the surgery performed by the surgeon using their surgical skills, experience, risk management and safety rules. Surgical robot is by far more advanced surgical instrument if compared to something that we had previously. I’m talking about open surgery and traditional laparoscopy. Robotic surgery offers simplification of complex surgical tasks by offering more precision in cutting, better visualisation, better surgical access and much less physical and mental demand from the surgeon. This allows us to perform very complex operations with more precision, less fatigue and achieve full removal of the disease while preserving the nerves, for fertility, bowel function, bladder function and sexual function in the patient.

Robotic surgery is associated with less complications, shorter lengths of hospital stay, less risk of conversion to open surgery compared to traditional laparoscopy and quicker patient recovery.

When did you decide to train in robotic surgery?

I have performed my first robotic case in January 2021 and have not performed any traditional laparoscopy since. I am now heading towards 500 robotic endometriosis  cases and have never looked back. The decision to switch completely to robotics came very easily after I had done my first five cases on the DaVinci Xi robot.  It wasn’t only significantly less physical and mental demand on the surgeon, but the whole surgical procedure experience has become more satisfactory, more elegant and more efficient.

“The message to myself was very simple: I can do it much better, much quicker and much safer on the robot”

Do you remember your first robotic surgery?

You always remember your first time. Prior to starting robotics I was an established high-volume advanced laparoscopic surgeon specialising in complex benign gynaecology. The way my first robotic case was conducted was very organised and structured.

Before approaching real patients I had to perform multiple hours of robotic simulation practice which gave me scores for each exercise. After that I went to observe live robotic surgery in Europe and finally had advanced final training on the robot in one of the robotic training centres. For my first case, the robotic proctor was invited to supervise my surgery. It happened to be world-famous robotic surgeon Mr Tony Chalhoub, who is now my dear friend. His job was to observe my surgery and make sure I don’t have any difficulties using new surgical equipment. My learning curve was very steep as I did not have to learn surgery, I just needed to get used to using the robot as a new laparoscopic instrument. I am now a robotic surgery proctor myself going around the UK and Europe and supervising robotic surgeons at the start of their robotic programme.

Both laparoscopic and robotic surgery have multiple benefits for patients, but for some patients it is very hard to decide. What are the strongest benefits of robotic surgery for endometriosis that we can’t get with laparoscopy?

For me there is no doubt: robotic surgery allows me to see better, excise more endometriosis and damage less healthy tissues. Because of the robotic approach we are now doing much less full-length bowel resection for bowel endometriosis just because we can radically excise the disease robotically without reforming segmental resections. The benefits are well-known and published: reduced post-surgery pain and opioid demands, less blood loss, increased precision for more accurate endometriosis excision, faster recovery, shorter hospital stay, less risk of infection.

Postoperative adhesions and pain are the most common complaints of patients. Do robotic surgery reduce these issues?

Valuation of post-operative adhesions is a very difficult research task that in most cases requires repeat surgery to look at the adhesions. I don’t have any reliable data to support that robotic surgery causes less adhesions and scarring. However, my thought is this is definitely the case because we use much less surgical energy in tissue dissection compared with laparoscopic surgery and therefore less surgical trauma to tissues, which can influence excessive scar and adhesion formation.

Prof Horace Roman and others reported microscopic endometriosis. Can robotic surgery remove microscopic endometriosis?

Robotic vision is significantly better compared to traditional laparoscopy, simply because it’s a 3D high-definition video image. It does not go to microscopy level, but we can see small peritoneal endometriosis patches much better compared to conventional laparoscopy. Therefore robotics allows us to see more endometriosis and therefore perform more radical clearance of it.

Endometriosis is a complex disease and surgery can be very difficult, especially when it comes to multiple organs involvement, such as nerves and bowel. Is robotic surgery better indicated for nerve sparing and bowel resection?

Our specialist robotic multidisciplinary endometriosis team offers top surgical expertise in nerve-sparing and fertility-preserving treatment options for severe infiltrating endometriosis. Our aim is to avoid multiple surgical operations for deep endometriosis and clear the disease in a single surgical procedure, even if the disease affects multiple organs and systems. In order to achieve this, we use principles of “conservative radicality” described by Arnaud Wattiez, excising the disease in full while minimising damage to the ovarian reserve, other pelvic organs, nerves and blood vessels. For suspected deep infiltrating endometriosis of the bowel, we offer extensive pre-operative assessment including a special MRI scan to assess the extent of the disease before surgery. If the diagnosis is confirmed, patients will be offered a range of treatment options, all of which are performed as robotic keyhole surgery.

in my own audit comparing my last 50 laparoscopic cases in my first 50 robotic cases the surgical procedure time was 36 minutes quicker. In the robotic group length of stay came down from 2.4 to 1.6 days on the average robotic surgery compared to laparoscopy. There were less complications and conversions to open. 

Our innovative robotic surgical techniques include stapler discoid bowel resection, which allows us to remove deep infiltrating endometriosis of the bowel without removing the length of the bowel. This results in a lower complication rate, a low recurrence rate and a quicker recovery. We are one of the first specialist units in the UK to offer this technique widely, and our surgical audit data shows excellent results in our patients’ quality of life, pain levels and sexual function.

In addition to performing surgeries, you are also training doctors. How do you see the future of robotic surgery in endometriosis?

My strong opinion is that robotic surgery is going to replace traditional laparoscopy fully. The benefits of robotics are obvious and complex endometriosis is treated much better with robotics. The surgeon will last longer physically and mentally at the top of their surgical expertise and capacity using robotics. We had a similar revolutionary trend 30 years ago, where pioneers of laparoscopy replaced the open surgery approach for most surgical procedures. Similar trend with robotics replacing laparoscopy is inevitable and is happening right now.

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The  endometriosis patient is certainly a fighter, which is why the word “endowarrior”, in my opinion, is the one that not only characterises a patient profile, but honours the strength of the person who rises daily after the fight with chronic pain, infertility and the other effects of this disease, that torment and invalidate them in all roles, roles that are equally fulfilled with fragility and strength, as a couple, in their families and in society.

You have an impressive professional career. You are both by definition and by experience a surgeon of excellence. When did you know you wanted to do surgery?

I knew that regardless of the speciality I chose, I would dedicate myself body and soul to my patients and the profession that chose me. The choice of surgery is an assumed decision, without half measures. Out of the desire to help as many patients as possible, a surgeon spends a lot of time studying and learning surgical skills which involves a majority of time in the operating room. Moreover, the training process of the team and other surgeons that I train in minimally invasive gynecologic surgery requires effort and, at the same time, challenges the limits that younger surgeons have to overcome. All this career path builds the path to Excellence for those who are prepared to walk it, doubling passion with sustained effort and personal sacrifices. The objective is one: the joy of our performance is dedicated to the health and well-being of patients who need us.

You do extraordinarily hard work, give suffering women a new life, help them become mothers. What motivates you?

The answer comes naturally. When after “hard work”, where the struggle and effort belong primarily to our patients, you see that you contributed to a better life, by offering the appropriate therapeutic solution, that helped the patient regain their health and quality of life or become mother, after years of infertility, these are great achievements of the profession and what motivates us, at the same time.

You are a renowned gynaecological surgeon worldwide who surgically approaches a wide range of gynaecological conditions and onco gynecology. You are also among the few women who perform minimally invasive surgery, at the level of excellence. Is it an advanced level, is this performance difficult to achieve? 

I am honoured by these qualifications, that are based on 20 years of professional training in the vast spectrum of gynecological surgery, from the treatment of benign conditions, endometriosis, adenomyosis, uterine fibroids, to serious oncological suffering, difficult cases of cervical cancer, endometrium or ovarian cancer. The transition from classical surgery, to vaginal surgery and then to minimally invasive surgery, laparoscopy or robotics, all these milestones in surgical training allowed me differentiating approaches and challenged me to find new surgical solutions that will offer the best alternative therapeutic for patients. The current trend in surgery is minimal invasiveness, it is the most advanced method that we can put into practice today with the help of new technologies.

“Endomedicare Academy is a multidisciplinary centre, integrated around the most experienced surgical team in Romania, designed to offer one-stop-shop surgery”

You founded an academy entirely dedicated to endometriosis. Moreover, you are a mentor for the younger generation of doctors, and a source of inspiration for your colleagues. What part of your career attracts you the most, surgery or academics? 

It’s a very good question, but I can’t express a “preference”. Both roles determine the expertise, with their own perspectives, one of a theoretical order, the other from the perspective of the practitioner. I can only see them as complementary, and the expertise is essentially consensual between theory and practice, relative to the usefulness of the training medical process.

What is Elvira Bratilă like?

Looking back, I consider myself a fulfilled and certainly a person determined and dedicated to people, patients, and the medical teams that I formed, colleagues that I guide in their professional path. By contributing to the formation of a school of minimally invasive surgery in gynaecology, that is seen as a dream hard to achieve, I consider it a dream already fulfilled.

Returning to Endomedicare Academy, how was this project created and what makes it unique?

Endomedicare Academy is a multidisciplinary centre, integrated around the most experienced surgical team in Romania, designed to offer “one-stop-shop surgery”, i.e. surgery for excision of endometriosis lesions, complete, correct and minimally invasive, from the first intervention. We are constantly aware of our scope, in order to avoid repeated surgeries and to reduce the risk of recurrence. We are a united and consolidated team around the endometriosis patient offering minimally invasive surgery, at the internationally accepted quality standards and validated by EuroEndoCert, offering personalised and unique therapeutic solutions, since each patient is unique. 

The “Endomedicare Academy ” concept is built around the verb “to care”, translated as follows: quality medical care for endometriosis patients, 360 degrees around the patient, in a medical and holistic approach, body, mind, spirit. Each case is unique and complex in its essence.

Endometriosis is a complex disease that requires multidisciplinary treatment. At the Endomedicare Academy, you have an exceptional team by your side, part of which I got to know as a patient. You also have an exceptional general surgeon, Dr Rubin Munteanu, with the most surgical experience in Romania. How important is it to work with surgeons who are aces in their field?

Surgery is not a “one-person-show”, it is a contribution of a team that is allied to a common goal: the best for our patients. To offer the endometriosis patient an integrated approach, under the umbrella of a Center of Excellence, the sine-qua-non condition is the highly-specialised team in treating this disease and its complex forms, such as deep infiltrative endometriosis. Dr Rubin Munteanu is really an ace in the surgery of this difficult to manage form, and the cases we performed together and the lack of complications in our team’s experience confirm the choice of the most experienced team of endometriosis specialists in Romania. We have been together for over 6 years in this chemistry and we enjoy the performance, in a country where “everything is old and everything is new.”

You are one of the two endometriosis specialists in Romania, who run EuroEndo Cert certified endometriosis centres, following an external audit. You didn’t call yourself a Center of Excellence, you were given this title. What does this certification represent?

Endomedicare Academy received EuroEndoCert and European Endometriosis League validation and the title of “Center of Excellence in the diagnosis and treatment of endometriosis” 2 years ago. The certification of centres specialised in endometriosis requires compliance with quality criteria and standards that external auditors, centres specialised in pathology, request to see in the certification process. The meeting of these criterias and norms validates the expertise of the centre and offers the guarantee of credibility in relation to the medical services offered to patients. 

“At the upcoming Endometriosis European Congress 4 minimally invasive interventions for complex cases of endometriosis will be transmitted from the Memorial Hospital in Bucharest and from Porto Spain. The interventions in Bucharest will be performed by myself, Prof. Horace Roman and Mr. Shaheen Khazali, and the intervention in Porto will be performed by Dr. Helder Ferreira”

In June, the whole medical world will be watching you and Romania. The European Endometriosis Congress with you as a president will take place in Bucharest. What can you tell us about the science program?

Held under the auspices of the European Endometriosis League, the European Congress of Endometriosis will certainly be a reference event, with renowned specialists from all over the world,  announcing their participation already.

The scientific program covers the broad spectrum of the pathology, and the Congress events will certainly bring new perspectives and innovative approaches, in a pathology that never ceases to surprise us, by the complexity, by the specificity of the cases, by the multiple facets and forms of manifestation of the disease. I am talking about the announced scientific program: Endometriosis School, Endometriosis ultrasound diagnosis course, and of course, the Live-surgery session, which will bring to the attention of the Congress participants 4 minimally invasive interventions for complex cases of endometriosis, transmitted from the Memorial Hospital in Bucharest and from Porto Spain. The interventions in Bucharest will be performed by myself, Prof. Horace Roman and Mr. Shaheen Khazali, and the intervention in Porto will be performed by Dr. Helder Ferreira.

Do you have a message for colleagues from around the world who will visit Romania, as a point of reference on the endometriosis map?

I am honoured to host this large-scale scientific event in Romania, the European Endometriosis Congress being a landmark event in this field of endometriosis research and knowledge, a good opportunity to see colleagues from Europe and the world, renowned specialists in this pathology, again in Bucharest. The fact that Romania will become a point of reference on the honourable map of expertise in the diagnosis, treatment and minimally invasive surgery of endometriosis motivates me in my course to bring into synergy the opinion of relevant experts worldwide, in a pathology that requires overspecialization. I will be happy to welcome our guests in Bucharest, Romania, in June.

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Because there is no specialisation for endometriosis, surgeons that operate on endometriosis patients are obstetrician-gynaecologists. They are known as endometriosis specialists. What is an endometriosis specialist? 

An endometriosis specialist is usually a gynaecological surgeon who has focused their career in the field of endometriosis. She/He usually has advanced skills in laparoscopic and robotic surgery and works with a team of surgeons in other specialties. 

Why does endometriosis require specialist treatment? 

Because endometriosis is a challenging condition, from diagnosis to decision making for treatment to surgery. All of these stages have many complexities. A lot is at stake. For example, incomplete or low quality surgery can lead to serious consequences for the patient. 

Prof Horace Roman once said that there is a need for endometriosis to have its own speciality. Do you agree with this statement? 

There is no doubt that training for endometriosis at specialty level is lacking. In some countries the problem is bigger than others. I think each training system needs to search for the best ways to improve training in endometriosis care. 

“I suggest researching from multiple angles and not being shy about asking direct questions regarding the doctor’s experience, outcomes and philosophy”

You are a renowned endometriosis specialist, involved in training as well and the founder of a BSGE specialist centre that sees patients from outside the UK as well. How would you describe your activity? 

Our team cares for patients with the most advanced forms of endometriosis. They travel for their treatments, usually because their condition is very complex and requires a multidisciplinary team of surgeons. We do, however, look after patients with all levels of complexity. Our philosophy is that the patient should be at the centre of their own care and if surgery is decided upon, it should be complete. Having access to the latest robotic technology has allowed us to do more complex procedures better. I do think that the robot can make a difference in many cases. 

One of the difficulties that endometriosis patients are facing is incomplete or failed surgeries that were done by gynaecologists surgeons without training in endometriosis. As a patient what should I look for when searching for a specialist? 

I suggest researching from multiple angles and not being shy about asking direct questions regarding the doctor’s experience, outcomes and philosophy. If possible, connect to some patients treated by them but remember even the best surgeons have some unhappy patients. Volume matters and the time of a surgeon is limited. So, if a surgeon claims to be an expert in many different fields, they are probably not an expert in either of them. Also, choose your hospital carefully. You want to be treated within a health system that has very strict patient safety regulations and those heath systems are usually not the cheapest ones. 

Why is endometriosis surgery so complex and why doctors’ interest in endometriosis is limited? 

Surgery is complex because endometriosis can affect multiple different organs and it doesn’t follow any rules. It behaves in unusual ways and therefore each patient is different. The anatomy of the pelvis is complex and doing advanced laparoscopic and robotic procedures are technically challenging. Dedicating a career to a complex and challenging condition means a lot of sacrifice. It usually takes years of hard work, sleepless nights and perseverance. Not everyone is willing to make those sacrifices. 

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