The ESSI MUlTIMODAL Method
A treatment philosophy, not a single procedure
A multimodal surgical approach to endometriosis, adenomyosis, pelvic pain, and fertility.
Enhanced endometriosis surgery: a multimodal approach that combines complete excision with additional targeted techniques when a patient’s specific anatomy, symptoms, and fertility goals call for them.
Multimodal does not mean “more procedures for everyone”.
It means matching the right technology
to the right problem.
Endometriosis often travels with other contributors to pain and infertility, including adenomyosis, pelvic floor dysfunction, bladder irritation, bowel involvement, pelvic vein dilation, ovarian reserve concerns, fallopian tube scarring, adhesions, and nerve involvement.
Endometriosis often travels with other contributors to pain and infertility, including adenomyosis, pelvic floor dysfunction, bladder irritation, bowel involvement, pelvic vein dilation, ovarian reserve concerns, fallopian tube scarring, adhesions, and nerve involvement. Each contributor has a different anatomy. Each requires a different solution.
In a single coordinated operation and recovery, the ESSI team can address visible endometriosis and the associated conditions contributing to symptoms.
The goal is not to use every tool — it’s to identify every important driver of pain, dysfunction, or infertility, and treat the ones that are actually present.
A critical clarification
Enhanced means additive, not less aggressive
The ESSI Method is not a softer or less complete version of endometriosis surgery.
Complete excision remains the foundation.
When disease involves the bowel, bladder, ureter, diaphragm, or
thorax, those areas are addressed with the appropriate surgical expertise.
“Enhanced” refers to what can be added to that foundation — used only when the patient’s findings and goals justify them. They do not replace careful excision.
A critical clarification
Complete excision is the starting point,
not the destination
ESSI performs every component of comprehensive radical surgery – and adds what conventional care omits.
| Surgical component | Standard care | The ESSI Method |
|---|---|---|
| 1. Comprehensive excision — The foundation what every expert center should be doing | ||
| Complex excision of all visible disease |  |
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| Bowel resection / shaving when involved | |
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| Bladder excision when involved | |
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| Ureteric work when involved | |
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| Diaphragmatic excision when involved | |
|
| Thoracic excision when involved | |
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| 2. The enhancements — additional ESSI techniques applied selectively, based on each patient's diagnosis | ||
| Nerve-sparing technique | — | |
| Neurolysis (sacral, sciatic, pudendal, obturator) | — | |
| Targeted neuromodulation with Botox (pelvic floor, bladder, uterus, anorectal, vulvar) | — | |
| Microwave ablation of adenomyosis | — | |
| Argon-beam organ-sparing endometrioma treatment | — | |
| Reconstructive tubal surgery | — | |
| Ovarian rejuvenation (PRP) for fertility | — | |
| Hysteroscopy + cavity evaluation in fertility cases | — | |
| CD138 endometrial biopsy to rule out chronic endometritis | — | |
| Placental-membrane adhesion barriers | — | |
| Pelvic congestion ligation only after obstructive causes excluded | — | |
DISCOVER
Why a single-tool approach fails
Most surgical approaches treat endometriosis as a single problem with a single solution.
But by the time many patients reach expert care, they often have multi-organ, multi-mechanism disease built up over years.
A single surgery treats one problem, leaves the rest
This may include pelvic floor hypertonicity, adenomyosis, endometriomas, adhesions, nerve involvement, and vascular changes, each acting as its own source of pain or infertility.
A single-technique surgery cannot address a multi-system condition. Treating only the visible disease often leaves other drivers of symptoms untouched—leading to persistent pain and repeat procedures.
DISCOVER
The four pillars of the ESSI Method
Patients with Pelvic Venous Disease often endure years of discomfort and multiple specialist visits before receiving a diagnosis. The symptoms are distinct from other gynecological conditions and are often linked to position and gravity.
1. Complete excision is the foundation
Every procedure begins with meticulous laparoscopic or robotic excision of all visible endometriosis, including superficial, deep infiltrating, bowel, bladder, ureteral, and pelvic sidewall disease.
Excision is the non-negotiable groundwork that everything else builds on.
2. Nerve-aware surgery
Pain during or after sexual intercourse is common. Because sexual activity increases blood flow to the pelvis, the already congested veins become further engorged, leading to prolonged aching or soreness that can last for hours or even days after intimacy.
3. Pelvic floor and pain pathways
Because the pelvic veins are connected to the lower extremities, many patients experience symptoms in their legs as well. This can include visible varicose veins on the vulva, buttocks, or upper thighs. Patients may also suffer from leg heaviness, swelling, or unresolved leg pain even after receiving treatment for superficial spider veins.
4. Uterus, ovaries, tubes, adhesions, and vascular system
Endometriosis frequently coexists with adenomyosis, endometriomas, tubal damage, adhesions, ovarian reserve concerns, and pelvic venous disorders. The ESSI Method integrates these problems into the operative plan so they are not treated as afterthoughts.
A new branch of ESSI dedicated to
What ESSI can add when indicated
Each driver of pain or infertility maps to a specific ESSI modality, with a specific
purpose. Toggle between the two groups of drivers below.
| Problem identified | ESSI Modality | Purpose |
|---|---|---|
| Visible endometriosis lesions | Complete excision | Remove disease to clean margins whenever safely possible. |
| Bowel, bladder, ureter, diaphragm, or thoracic disease | Multispecialty excision | Address complex organ involvement in one coordinated operation when feasible. |
| Nerve involvement or entrapment | Nerve-sparing dissection + neurolysis | Treat nerve-related disease while protecting bladder, bowel, and sexual function. |
| Pelvic floor hypertonicity or trigger points | Targeted neuromodulation | Relax selected muscles and reduce painful nerve signaling so rehabilitation can work. |
| Adenomyosis with uterus-preservation goals | Organ-sparing uterine treatment | Treat uterine pain while preserving future fertility options when appropriate. |
| Problem identified | ESSI Modality | Purpose |
|---|---|---|
| Endometriomas with fertility concerns | Ovary-preserving endometrioma strategy | Balance disease control with protection of ovarian cortex and reserve. |
| Tubal damage or adhesions | Tubal reconstruction + adhesiolysis | Restore anatomy and evaluate whether natural conception is possible. |
| Fertility-focused case | Hysteroscopy + CD138 biopsy when indicated | Identify cavity pathology and chronic endometritis before fertility treatment. |
| Symptomatic pelvic venous disease | Selected vascular intervention | Treat refluxing dilated veins only after obstructive causes are excluded. |
| High adhesion risk | Structured adhesion prevention | Reduce the chance that scar tissue reverses the surgical result. |
| Diminished ovarian response | Ovarian PRP in selected cases | Investigational adjunct considered only after counseling about evidence and uncertainty. |
A critical clarification
Treating nerves and muscles, not just disease
Pain in endometriosis can come from more than lesions.
Pelvic floor spasm, bladder urgency, uterine cramping, anorectal spasm, and vulvar pain can each be driven by different neuromuscular pathways. Removing endometriosis alone may not fully reset those pathways.
When clinically indicated, ESSI uses targeted neuromodulation with botulinum toxin A. The goal is precision: treating the mapped pain generator, not injecting everywhere. In selected patients, this can relax chronically contracted muscles, reduce abnormal nerve signaling, and create a temporary window for physical therapy and functional recovery.
Pelvic floor dysfunction
High-tone pelvic floor, deep dyspareunia, levator myalgia.
Bladder pain or urgency
Selected cases of refractory urgency, frequency, or bladder pain syndrome.
Uterine pain
Severe dysmenorrhea or adenomyosis-related uterine cramping in selected patients.
Anorectal pain
Sphincter spasm, anismus, or rectovaginal pain syndromes.
Vulvodynia or vaginismus
Superficial pelvic floor targets when clinically mapped.
Endometriosis & FERTILITY
Fertility-aware endometriosis surgery
A fertility-aware operation is not simply a pain operation that leaves the ovaries behind.
It is a different surgical philosophy.
Every step is planned to protect ovarian reserve, restore anatomy, evaluate the uterus, prevent adhesions, and coordinate with reproductive endocrinology.
01 Protecting the ovaries
For many endometriomas, standard surgical removal is appropriate. In patients with bilateral disease, diminished reserve, prior ovarian surgery, or active fertility goals, ESSI may use ovary-preserving techniques — such as argon-beam treatment of selected cyst-wall surfaces — to reduce unnecessary loss of healthy ovarian cortex. The choice is individualized to the anatomy and fertility plan.
02 Ovarian PRP / ovarian rejuvenation
For selected patients with diminished ovarian reserve or reduced ovarian response, ESSI offers intra-ovarian platelet-rich plasma (PRP) as an emerging adjunct. This is investigational and not guaranteed to improve outcomes. It is considered only after discussion of the current evidence, uncertainty, cost, and alternatives.
03 Restoring the fallopian tubes
When fertility is a goal and tubal anatomy can be reconstructed, ESSI may perform adhesiolysis, fimbrioplasty, or neosalpingostomy rather than defaulting immediately to removal. The goal is to restore anatomy when it is reasonable and safe to do so.
04 Evaluating the uterine cavity
In fertility-focused cases, hysteroscopy can be performed under the same anesthetic to evaluate the uterine cavity. Polyps, adhesions, retained tissue, or a clinically significant septum can be treated in the same setting. CD138 endometrial biopsy may be used to evaluate for chronic endometritis, a treatable inflammatory contributor to implantation failure and pregnancy loss in selected patients.
05 Adhesion prevention & fertility coordination
Adhesions can undermine fertility and pain outcomes. ESSI uses meticulous tissue handling and selected anti-adhesion barriers when appropriate. Postoperative timing is coordinated with reproductive endocrinology so surgery supports the next fertility step rather than delaying it unnecessarily.
Targeted neuromodulation
A multispecialty team in the same operating room
Colorectal
Urologic
Vascular
Thoracic
A multimodal approach requires a multispecialty team. Endometriosis can involve the bowel, bladder, ureters, diaphragm—even the lungs and liver.
ESSI brings colorectal, urologic, vascular, and thoracic expertise into a single operating room, not through separate referrals. When multiple specialties are needed, they operate together—so the patient has one surgery, not three.
“
Excision treats the disease.
The ESSI Method treats the patient.
Endometriosis Surgical Specialists International
Who the ESSI Method is for
Designed for patients who need more than one tool
- Have known or strongly suspected endometriosis with a complex pain picture beyond just menstrual symptoms.
- Have had one or more previous surgeries and continue to have pain.
- Are pursuing fertility and want surgery designed around that goal, not against it.
- Have coexisting adenomyosis and want to preserve their uterus.
- Have known endometriomas and worry about repeat surgery and ovarian reserve.
- Have damaged or distorted tubes and want to know whether reconstruction is possible.
- Have nerve-related symptoms — sciatica, pudendal pain, urinary or bowel dysfunction — no one has connected to endometriosis.
- Have been told their pain is psychosomatic, untreatable, or out of proportion to imaging.
- Have been offered a hysterectomy as the only option and want to know if there’s anything else.
- The ESSI Method is not the right approach for every patient. We will tell you directly if a simpler operation, a non-surgicalpathway, or a referral elsewhere is more appropriate.
FAQS
Frequently asked questions for The ESSI Method
Is the ESSI Method one operation or several?
One operation. All identified contributors to pain or infertility are addressed under the same anesthetic, with one recovery, not multiple procedures.
How is this different from other endometriosis surgeries?
Many centers perform expert excision. ESSI combines that with nerve-sparing surgery, neurolysis, targeted neuromodulation, adenomyosis treatment, fertility-preserving techniques, vascular intervention, and adhesion prevention—all in the same operation.
Will I still need treatment after surgery?
Usually, yes. Surgery is the foundation, but recovery often includes pelvic-floor physical therapy, medical management, fertility care, and long-term follow-up.
I’ve had prior surgeries. Can this still help?
Often, yes. Re-operative cases are common, and a multimodal approach becomes even more important when prior treatment addressed only part of the problem.
Does this support fertility?
Yes. ESSI prioritizes ovarian preservation, tubal repair, treatment of adenomyosis, and adhesion prevention, while coordinating with reproductive endocrinology.
Is it covered by insurance?
Most procedures are recognized, but coverage varies by plan and indication. Our team reviews this with each patient before scheduling.
How do I know if I’m a candidate?
Schedule a consultation. We review your history, imaging, and prior reports, perform a comprehensive pelvic and pelvic-floor evaluation, and create a personalized plan.
A different standard
A different standard
There is strong evidence for each component of the ESSI Method
but few centers combine them in a single operation.
Excision, nerve-sparing surgery, neurolysis, neuromodulation, adenomyosis treatment, vascular intervention, fertility-preserving techniques, and adhesion prevention.
The team brings these together into a comprehensive, individualized surgical approach,
designed for patients who need more than a single-tool solution.
