Before paying cash for endometriosis surgery, compare expertise, outcomes, and insurance-based options.

Small, superficial implants on the peritoneum. No significant scarring or adhesions. Bowel, bladder, and ureter surgery are not required. Excision by a GYN-oncology trained surgeon is the standard approach. No general surgeon or urologist needed.

Deeper implants, possible small endometriomas. Minimal adhesions. Most Stage II patients do not require bowel, bladder, or ureteral surgery. Retroperitoneal excision technique removes deep implants thoroughly. Recovery is typically straightforward.

Multiple implants, possible endometriomas, significant adhesions. Some bowel involvement may be present. Retroperitoneal technique is critical here. Many Stage III cases still do not require bowel resection — shaving or serosal excision may suffice. Ureterolysis may be needed but rarely requires a urologist.

Extensive disease, large endometriomas, dense adhesions. Bowel, bladder, and ureteral involvement is possible. Even in Stage IV, most bowel involvement is managed with shaving or serosal excision — not resection. Requires the highest level of surgical training. GYN-oncology training is the appropriate credential.

Most patients with bowel symptoms do NOT require bowel resection

Patients are frequently told they have “bowel endometriosis” and assume this means major bowel surgery. In most cases, it does not. Published data shows that in the hands of experienced surgeons, shaving technique alone is possible in more than 95% of colorectal endometriotic nodules — with lower complication rates than resection and comparable recurrence rates. (Laparoscopic shaving for colorectal endometriosis: a literature review, IJRCOG 2024)

The extent of bowel involvement determines the operation. Most bowel involvement does not require resection. Approximately 24% of all endometriosis patients have sigmoid or rectal involvement — but even among those, shaving or serosal excision is the most appropriate technique in the majority of cases. (Colon resection for endometriosis, PMC 2020)

Bladder involvement does not mean bladder repair — most cases are resolved with retroperitoneal excision only

Ureterolysis is not ureteral reimplantation — understanding the difference protects you

What GYN-oncology training covers

• ✓ Advanced retroperitoneal dissection — working behind the peritoneal lining to expose ureters, vessels, and nerve structures before removing disease
• ✓ Ureterolysis — freeing the ureter from surrounding disease without cutting it
• ✓ Vascular control — managing bleeding from major pelvic vessels during complex dissection
• ✓ Bowel surgery — serosal excision, discoid excision, and segmental resection when required by disease extent
• ✓ Bladder excision and repair — partial cystectomy when disease infiltrates the bladder wall
• ✓ Diaphragm surgery — excision of disease from the diaphragm in patients with right shoulder pain and thoracic involvement
• ✓ Radical pelvic surgery and reconstruction techniques

What this means for endometriosis patients

A GYN-oncology trained surgeon can manage advanced pelvic procedures without defaulting to additional surgical specialists for organ involvement. Additional specialists are involved when the patient’s specific disease extent requires their expertise — not simply because the operation is complex.

This distinction matters enormously for patients. A surgeon who requires a colorectal surgeon for every case of bowel involvement — regardless of the actual disease extent — is working at the edge of their training. A GYN-oncology trained surgeon determines what each case requires and involves additional expertise only when the patient’s disease makes it necessary.

You pay the surgeon $15,000–$50,000 cash upfront — before surgery

The surgeon collects their full fee directly from you before you enter the operating room. This payment is to the surgeon only — it does not cover the hospital, the anesthesiologist, the operating room, or any other facility costs. Those are billed separately.

Surgery is performed at an in-network hospital — the facility bills your insurance at in-network rates

The hospital, the operating room, anesthesia, and nursing are billed to your insurance at in-network rates. You pay your normal in-network cost-sharing for the facility only — your deductible and coinsurance. Some cash-based surgeons present this as evidence that the procedure is "covered by insurance." It is not. The facility is in-network. The surgeon is not.

The surgeon files a claim to your insurance for their fee — as a courtesy

Some cash-based surgeons will submit a claim to your insurance on your behalf after surgery. This is presented as a benefit — "we handle the insurance paperwork for you." What this means in practice: the insurance company receives the claim, processes it at the out-of-network allowed amount, and sends a reimbursement check. The surgeon has already been paid in full. The check goes to you.

Your insurance reimburses $750 to $1,500 — weeks or months later

The out-of-network reimbursement from your insurance for a $20,000+ surgical fee is typically between $750 and $1,500. Many patients expect a substantial reimbursement — this expectation is not corrected before surgery. The insurance company calculates the reimbursement based on the out-of-network allowed amount, which bears no relationship to what the surgeon charged. Your net out-of-pocket cost for the surgeon alone: $18,500 to $24,250+.

What are the possible scenarios for my surgery — and what would each require?

No surgeon can tell you definitively what operation you will need before surgery. Endometriosis can only be staged at the time of laparoscopic surgery, confirmed by pathology. Imaging may provide some insight — an MRI may suggest deep infiltrating disease — but it will not always be accurate, and it cannot determine the full extent of disease. A good surgeon will walk you through the range of possibilities based on your symptoms and imaging and explain what each scenario would require. Be cautious of any surgeon who tells you definitively what surgery you need before operating.

Are you GYN-oncology trained — or an MIS fellowship?

These are different trainings. A GYN-oncology training covers retroperitoneal dissection, ureterolysis, bowel surgery, bladder surgery, and vascular control. An MIS fellowship covers laparoscopic technique and generally not organ surgery at this level. Ask specifically which fellowship was completed and where.

How often do your patients require bowel resection — and how often do you bring in a colorectal surgeon?

Most patients with bowel involvement do not require segmental resection. A surgeon who routinely involves colorectal surgeons may be doing so because their training requires it — not because your disease requires it. Ask for their actual numbers.

Do you use excision or ablation — and do you ever use ablation for any endometriosis?

Complete excision is the standard of care. Ablation burns the surface and leaves disease at its root. Any surgeon who uses ablation for endometriosis — even “just for small implants” — is not performing complete excision.

How often do you convert to open surgery — and what is your published conversion rate?

A surgeon who rarely converts to open is a surgeon prepared for the full range of what their cases present. CIGC’s endometriosis excision cases are performed laparoscopically with a conversion to open rate approaching zero — including cases involving Stage IV disease on bowel, bladder, ureters, and diaphragm. Ask any surgeon you are considering for their actual conversion rate specifically for endometriosis cases.

Have you published outcomes in a peer-reviewed journal — and what is the PubMed ID?

Patient reviews, word of mouth, and self-reported success rates are not clinical evidence. Published peer-reviewed outcomes are. Ask for the journal name, volume, and PubMed ID. Verify it yourself at pubmed.ncbi.nlm.nih.gov. CIGC’s seven-year endometriosis outcomes: AJOG 2021, Danilyants N, MacKoul P et al.

How many endometriosis excisions do you perform each year — and what percentage involve organ surgery?

Surgical volume is a documented predictor of outcomes for complex procedures. A surgeon who performs a high volume of complete excisions — including cases with organ involvement — has the pattern recognition and technical fluency that only comes from sustained practice at high volume.

Will my fee increase if more disease is found during surgery — and who are all the providers who may bill me?

Cash-based surgeons sometimes charge additional fees when more disease is found than anticipated. Additional out-of-network providers — colorectal surgeons, urologists, surgical assistants — who assist on the case may also bill separately, also out-of-network. Clarify the total billing picture before surgery, not after. At CIGC, your cost is your normal in-network cost-sharing — no surprises.

Why are you not in-network with insurance?

Being out-of-network is a billing decision, not a clinical credential. It does not certify a higher level of training or technique. It means the surgeon has chosen not to accept insurance reimbursement rates. CIGC accepts in-network insurance rates and delivers GYN-oncology trained, complete excision surgery at a freestanding surgery center — with published outcomes to verify the results.