Prof Dr Elvira Bratila - da vinci surgery

The difference between classical, laparoscopic and robotic approach for endometriosis

Endo-Q&A. Endometriosis Patient Experience and a Question

How do we avoid incomplete, incorrect surgery and decisions that can really affect our future?

The difference between classical, laparoscopic, and robotic surgery in deep infiltrating endometriosis (DIE) excision surgery.

We know that the classic surgery unfortunately requires a much longer healing time and we recover much harder. What we may not all know is that the classic operation is no longer recommended in endometriosis and is a last option, unless there really are no other options especially in cases where the adhesions are so entrenched in the belly that the laparoscopic arm could not pass.

The classic operation unfortunately does not help much in our disease either, because deep infiltrating endometriosis cannot be successfully cleared. This is because the human eye does not have the power to analyse microscopically and automatically not all endometriosis foci will be seen with the naked eye. As a result, after such an operation, apart from the fact that you will not have such an easy recovery, it is very possible that after a few months after the operation the endometriosis will reappear and you will need to have another operation.  So when you get the news that you have to have the operation and you are told that you should have it done classically, you would do very well to inform yourself carefully about the surgeon’s experience and think carefully beforehand.

The second and most common type of surgery in excision surgery of endometriosis lesions is laparoscopic surgery.

The difference between classical, laparoscopic and robotic approach for endometriosis

Here the incisions are relatively small, somewhere between 5 and 10 mm depending on the instruments used, usually 3 or 4 in number, the recovery time is clearly superior to the classic operation and, in addition, the results of the operation can be very good even long afterwards.

Laparoscopic surgery is performed as follows: an incision of about 1 cm is made for optic system and the abdominal cavity is opened. In order to see the abdominal space better, gas is introduced, so that after inserting a special optical tube, the organs of the abdominal cavity can be visualized very well.

Then, in the lower part of the abdomen, on the right and left, small incisions of between 5 and 10 mm can be made, allowing special instruments to be inserted. This makes it possible to operate and clean the abdomen.

With this type of operation medicine aims at replacing a classic surgery involving a large and painful incision in the abdomen.

This type of surgery is also performed under general anaesthesia and with a period of hospitalization of one to three days depending on organs afected by Deep infiltrating endometriosis.


Laparoscopy has many advantages. Some of them below:

  • the risk of infection and thromboembolism (blocking a blood vessel with a clot and transporting it, for example, to the lung) is lower compared to the classical surgical technique;
  • post-operative complications are reduced, post-operative recovery time is much shorter- if the surgeon is skilfull
  • laparoscopic surgery causes less post-operative pain and the cosmetic result is better;
  • much lower risk of vascular lesions, bladder injuries.

Unfortunately, after laparoscopy, tummy aches and shoulder pain may occur, which are the result of an irritation of the diaphragm due to the gas introduced into the abdominal cavity for better visualization of the organs, but they usually disappear after 2 days. These pains, which can also occur in the ribs or when breathing, are unpleasant and create discomfort, but they are harmless and need not worry you. 

The most advanced approach in deep infiltrating endometriosis excision surgery is robotic surgery.

Prof Dr Elvira Bratila - da vinci surgery

If 2-3 years ago, laparoscopic surgery was the “golden standard” for the diagnosis and treatment of endometriosis, robotics is starting to be accessed in endometriosis as well, with good results for the quality of life of patients after these surgeries.

Robotic surgery is an advanced form of minimally invasive surgery. During surgery the abdominal wall is no longer incised, 4 small incisions are made, allowing for a quick post-operative recovery.

The robotic system is called “da Vinci” and is a sophisticated platform that has been designed to amplify and extend the surgeon’s capabilities. With the da Vinci, 4 specially designed trocars (arms) are inserted through these incisions to reduce trauma to the abdominal wall in order to reduce post-operative pain. Through these trocars, miniaturized working instruments and a high definition 3D/HD camera are inserted.

Unlike open surgery (through a wide incision in the abdomen) where the surgeon, although having good visual access, in deep areas of the pelvis only has digital access. In robotic surgery the camera has access to deep areas of the pelvis giving the advantage of image magnification. For this reason, surgical gestures are much safer, because in these spaces there are vascular and nervous structures that need to be protected in order to ensure a good quality of life after surgery.

The use of the 3D/HD camera allows the identification of more than 98% of endometriosis lesions.

In the pathology of women in the fertile period, the accuracy offered by robotic resection is superior. Surgical treatment of an endometriosis cyst is a sensitive issue for infertility patients. The aim of surgery is to excise the lining of the ovarian cyst and to preserve as much ovarian tissue as possible because the quantity of oocytes in these patients is low anyway. This is important for the patient regardless of whether she chooses to procreate naturally, by artificial insemination or in vitro fertilisation.


The patient’s benefits following robotic surgery are important to the patient:

  • decreased postoperative pain;
  • minimized risk of bleeding after surgery;
  • much lower risk of vascular injury, bladder, ureter, or rectal injury;
  • shorter recovery time;
  • no trauma to the abdominal wall;
  • lower rate of complications;
  • reduced hospitalisation time;
  • fast post-operative recovery, within 48 hours you can be discharged.

We are fortunate to finally have access in Romania to this wonderful technique called robotic surgery. Unfortunately, there are extremely few doctors specialized in robotic surgery.                                                                                                                      

Elvira Brătilă, MD, PhD, Ob-Gyn Senior Specialist

Professor Elvira Bratila is one of the few doctors with such skills and is the only surgeon in Romania doing robotic surgery in endometriosis.  Professor Elvira Bratila has over 5 years of experience in robotic surgery and over 15 years of experience in laparoscopic surgery.

“I would like to emphasize that years of experience in minimally invasive laparoscopic surgery are very important when you come into contact with robotic surgery, because without the knowledge acquired in the interaction with the laparoscope you cannot discover the mysteries of robotic surgery. It’s like skipping a few chapters in a book and not understanding anything about the story.” 

Take home message: Robotics in endometriosis has a low conversion rate to traditional surgery (via large abdominal wall incision), so you can count on the fact that if you have chosen this route you won’t wake up after surgery with a large abdominal wall cut. (That’s not called “minimally invasive surgery”).


Tips & tricks:

  • Ask all the questions about the surgical approach so you can make an informed decision.
  • Make sure you understand the surgical approach from the start.
  • Choose carefully the right path and the right surgeon.