Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.
Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease, since the "evidence" presented in a medical journal becomes a matter of opinion rather than a matter of fact.
No long term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.
A surgeon has only two senses that can be used at the operating table: sight and touch. Laser vaporization sacrifices touch entirely and obscures visual cues with carbon residue and smoke. Laser vaporization can leave carbon deposits which can be mistaken later for recurrent disease.
A laser is an expensive machine and therefore factors into higher healthcare costs. Simpler surgical methods, such as sharp excision, have proven highly effective in eradication of disease and are considerably less expensive. Widely used in the laparotomy era, excision has a long track record of effectiveness in eradicating the disease.
Use of the laser for endometriosis surgery has not been proven superior to conventional surgery with scissors and blunt dissection, nor has it been proven for any other gynecologic surgery. In fact, one study noted that surgical scissors cause less tissue reaction than carbon dioxide laser when used for cutting.
I began removing disease through the laparoscope long before laser was generally available in America. The results were excellent without the use of laser technology and there seemed little reason to change. Another consideration is this: if a surgeon were to change his technique frequently or add medical therapy to his surgical efforts, this would dilute and obscure the real effects of that surgical therapy. My efforts have been directed along the same lines of sharp excision, whether at laparotomy or laparoscopy, since 1980. Since I have not routinely used any other treatments for endometriosis, my outcomes give a fairly pure idea of what excision can do.