Bread and Butter of Endometriosis Surgery: A Call for Standards That Elevate Education and Outcomes

Defining the Bread and Butter of Endometriosis Surgery: A Call for Standards That Elevate Education and Outcomes  

Discussions about “endometriosis centers of excellence” often emphasize multidisciplinary care, imaging access, pain specialists, fertility services, and patient support infrastructure. These components matter, but they orbit around the true center of gravity: the surgeon. The single most important determinant of outcomes in advanced endometriosis is the ability of the operating surgeon to safely and reproducibly perform the core operation of the field. Yet, despite decades of progress in diagnosis and multidisciplinary management, gynecology has never defined what surgical excellence in endometriosis actually entails. 

A major source of confusion stems from the assumption that an endometriosis surgeon must independently perform bowel, gastrointestinal, or genitourinary resections. In reality, the ability to perform multi-organ surgery varies dramatically across hospitals, states, and countries, shaped by local credentialing processes, institutional culture, and medicolegal climate. These variations are structural, not reflective of surgical judgment or capability. For this reason, multiorgan resection should never be used as the yardstick for defining an endometriosis surgeon. The true standard is far more fundamental: mastery of the bread-and-butter operation—stage IV endometriosis with obliteration of the culdesac—whether the goal is fertility preservation or a modified radical hysterectomy. 

This operation is the crucible of the specialty. It demands anatomic fluency, retroperitoneal dissection, restoration of normal pelvic relationships, and the ability to navigate a frozen pelvis without injury. These are not “superspecialist” skills; they are the essential competencies that any center claiming excellence must demonstrate. Yet, unlike other complex surgical fields, gynecology has never articulated the minimum operative standards required to perform this work safely and consistently. 

Other specialties have shown us how transformative such standards can be. The landmark video-based criteria for total mesorectal excision in rectal cancer created a shared language for quality, training, and accountability. Endometriosis surgery deserves the same rigor. A Delphi based process—drawing on experts in fertility preserving surgery and advanced hysterectomy—can distill the essential steps, anatomic landmarks, and decision points that define competence in a frozen pelvis. Delphi methodology forces clarity, reduces variation, and produces consensus criteria that can be taught, assessed, and improved. 

The educational impact of such criteria would be profound. They would provide trainees with a roadmap for progression, give practicing surgeons a framework for self-assessment, and allow institutions to credential based on demonstrated skill rather than case numbers or assumptions. They would also create a foundation for structured mentorship, simulation, and video-based coaching, elements that are currently fragmented and inconsistent. 

Looking ahead, AI assisted video review will amplify these benefits. Machine learning models are already capable of identifying anatomic structures, mapping instrument movements, and evaluating completeness of dissection. With consensus criteria in place, AI could score operative videos, flag deviations, and provide objective, scalable feedback. Rather than replacing expert judgment, AI would democratize it—bringing the insights of master surgeons to every training program and every operating room. 

If endometriosis care is to evolve, we must stop defining excellence by infrastructure and start defining it by skill. Establishing surgical standards is not merely an academic exercise; it is the foundation for safer operations, better training, and a future where expertise is measurable, teachable, and universally accessible. 

References 

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