Laparoscopy and robotic-assisted surgery for endometriosis: how intestinal and ovarian involvement impact operative...

Surgical duration for endometriosis treatment varies based on the anatomical complexity of the disease and the surgical technique applied. However, the independent effects of each of these factors remain poorly understood. We hypothesized that intestinal involvement and the presence of endometrioma, whether isolated or combined, significantly increase operative time, regardless of the surgical technique. This study aimed to assess how endometriosis phenotype and surgical approach influence operative time. This retrospective observational study included 263 patients who underwent either conventional laparoscopy (n = 113) or robotic-assisted surgery (n = 150) between January 2020 and December 2024. Patients were stratified into four groups: (1) isolated deep infiltrating endometriosis, (2) endometrioma without intestinal involvement, (3) intestinal endometriosis without endometrioma, and (4) combined presentation (endometrioma with intestinal involvement). Univariate analyses and multiple linear regression models were used to examine the effects of disease phenotype and surgical approach on operative time. A p value < 0.05 was considered statistically significant. The presence of endometrioma and intestinal involvement were both significant predictors of increased operative time, with a cumulative effect in combined cases. Compared to isolated DIE, there was an average increase of 63.4 min for isolated endometrioma cases (p < 0.001), 40.9 min for isolated intestinal endometriosis (p = 0.004), and 103.8 min for combined presentation (p < 0.001). The robotic approach added an average of 34.0 min to operative time (p < 0.001), with the effect most pronounced in patients with endometrioma. Age was also a significant factor, contributing an additional 1.5 min per year (p = 0.035). The estimated mean docking time for robotic cases was approximately 12 min. When stratified by disease subtype, only the isolated endometrioma group showed a statistically significant difference between surgical techniques, with robotic-assisted surgery adding 55 min (p = 0.007). In the other groups, including those with intestinal involvement, no significant differences were observed between approaches, although there was a numerical trend towards longer operative times with the robotic technique. Operative time is primarily influenced by the clinical presentation of endometriosis, with endometrioma, especially when combined with intestinal involvement, having the greatest impact. Although robotic-assisted surgery was associated with longer operative times overall, it was more frequently used in complex cases, suggesting a positive selection bias. The additional time likely reflects both the technical intricacy of robotic procedures and the docking process. Nevertheless, this technology may offer advantages for complex dissections. These findings underscore the importance of individualized surgical planning based on the anatomical characteristics of the disease rather than solely on the choice of surgical platform.