ROLE OF 2nd LOOK LAPAROSCOPY IN ENDOMETRIOSIS BY DR SHASHWAT JANI

1. Second Look
Laparoscopy for
Endometriosis
Dr. Shashwat Jani.
M.S. ( Gynec)
Diploma In Advance Endoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College,
Sheth V. S. General Hospital, Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Mob : 9909944160 Dr. Shashwat Jani 2
Greetings From Ahmedabad …

3. Endometriosis : Incidence
 3 – 10 % of women of reproductive age
 20 - 40% in infertile women
 5 - 30% with chronic pelvic pain
 20 - 50% asymptomatic, found during
laparoscopy and sterilization.
 50 % dysmenorrhea
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5. It’s very Frustrating …
 Women - No definitive cure.
 Physicians – Symptoms not correlating with
the extent of the disease.
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6. Definition
 Second-look laparoscopy is
performed after a procedure OR course
of treatment to determine if the patient
is free of disease.
 If disease is found, additional
procedures may or may not be performed
at the time of second-look laparoscopy.
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7. Indicated in…
1 ) When there is recurrence of the disease.
2 ) To see whether medical therapy is effective
or not
3 ) When primary surgery was incomplete due
to advanced disease.
4 ) When there is Chronic pelvic pain
5 ) Before going for any major Assisted
reproductive technique.
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8. 1 ) Recurrence
 Recurrence nearly always means reappearance
of the disease following treatment – either medical
or surgical.
 Even TAH – BSO is not absolutely recurrence proof
as traditionally believed.
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9.  Endometriosis has a High likelihood of
recurrence
Progressive disease
Most treatments focus on Management of
symptoms.
No treatment has been shown to prevent
recurrence.
Recurrent rates vary with different treatment
modalities.
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10. • 4 yrs Recurrence rate :
• 24.6% Ovarian endometrioma.
• 17.8% Pelvic endometriosis.
• 30.6% Deep infiltrating disease.
• 23.7% Ovarian + pelvic
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11. Stage of the disease :
• 37% - 3 years – Stage I (or) II minimal disease
• 74% - 3 years – Stage III & IV severe
endometriosis
 More advanced the stage of disease at
the time of initial surgery, the higher the rate
of recurrence.
(AJOG, 2008 March)
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12. Endometrioma recurrence
• More common when the endometrioma is
removed piecemeal and the tissue planes are
scarred
• More common when the ovarian reserve is
better.
Somigliana et al.
AJOG 2011
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13. The reported recurrence rate was high,
estimated as 21.5% at 2 years and
40-50% at 5 years.
(23 years follow up)
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14. 2 ) Effectiveness
of Treatment :
• If pt. is on Medical therapy for
3 / 6/ or 9 months , and still
complain persists then , she should
be advised to undergo Second look
laparoscopy to access the
effectiveness of the medical therapy.
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15. How effectively do hormonal drugs
treat endometriosis associated pain?
• Suppression of ovarian function for 6 months reduces
endometriosis - associated pain.
But , Symptom recurrence is common following medical
treatment of endometriosis.
• Medical treatment does not always provide complete
pain relief and some women fail to respond at all.
• Symptom recurrence is common following medical
treatment. In a retrospective study , following
hormonal treatment, the median time to recurrence of
pain was 6.1 months for danazol-treated women and
5.2 months for those treated with a GnRH agonist.
( Endometriosis.org )20-Jan-16 Dr Shashwat Jani 9909944160

16.  A 6-month course of hormonal suppression treatment
or dietary therapy after laparoscopic cystectomy had no
significant effect on the recurrence rate of ovarian
endometriosis when compared with surgery plus
placebo.
 So, treatment of endometrioma can be carried out
exclusively by laparoscopic cystectomy without post-
operative therapy, if a complete excision of ovarian
endometriosis has been assured.
Sesti F, Capozzolo T, Pietropolli A, Marziali M, Bollea MR, Piccione E.
Recurrence rate of endometrioma after laparoscopic cystectomy: a comparative randomized trial between post-operative hormonal
suppression treatment or dietary therapy vs. placebo.
Eur J Obstet Gynecol Reprod Biol. 2009 Nov;147(1):72-7.
Recurrent Endometriosis
GnRH Analogues
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17.  In a recent trial,
women were randomized to undergo immediate
laparoscopic ovarian cystectomy OR a 3 step protocol,
which involved endometrioma drainage, 3 months of
subsequent GnRH agonist therapy and a second look
laparoscopy for laser coagulation of the cyst wall.
Women who underwent the 3 step procedure showed a
greater increase in AMH level and a more significant
increase in antral follicle count, than women undergoing
the single step procedure.
This may indicate that ovarian function is better preserved
following a three step surgical procedure, rather than the
traditional single step approach.
(Tsolakidis, 2009 )
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19. 3 ) Second stage surgery
When primary surgery was incomplete,
may be due to ….
1 ) Advanced stage of disease
2 ) unavailability of resources in Operative room
3 ) Lack of expertise of surgeon
4 ) Surgery abandoned due to Intraoperative
complication
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20. “ Second look laparoscopy
should be done in all above cases
after medical therapy of 6 to 9
months .”
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21. PubMed
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22. 4 ) Chronic Pelvic Pain
 Its becoming one of the most common
gynecological disorders & is found to be
associated with approximately 50 % of patients
with chronic pelvic pain.
 Pelvic pain , dysmenorrhea, Dyspareunia
are the are chronic , recurrent and persistent
with endometriosis.
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23. Recurrence & Problems
1.Impaired Quality of Life
(Pain)
2.Infertility
3.Endometrioma
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24. Impaired QoL ( Pain )
Mx
1.Second Laparoscopy Surgery
2.Medical Suppression
3.Expectant Management
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25. Impaired QoL
Second Laparoscopy Surgery
• Re-Excision
• Pelvic Denervations
–Presacral Neurectomy
–LUNA
• Hysterectomy
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26. Repetetive Surgery for Pelvic Pain
Berlando N, Curr Opin Obstet Gynecol 2010,
2nd Surgery 3rd Surgery
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27. Re-Excision
• 81 women re-operated, 60 months
Laparotomy (n = 41) Laparoscopy(n = 40)
Stage IV………………..14………………………………….. 11
Stage III ………………..25………………………………….. 21
Stage II…………………..0……………………………………...2
Stage I…………………… 2……………………………………...6
Dysmenorrhea……..22%(7/32)………………………29%(10/35)
Deep dyspareunia.. 30%(7/23)…………………….25%(4/16)
Pelvic pain............... 35%(9/26)..................... 32%(7/22)
Busacca M, Fedele L, Bianchi S, et al.
Surgical treatment of recurrent endometriosis :laparotomy versus laparoscopy.
Hum Reprod 1998;13:2271–4.
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28.  According to Cochrane systematic review
considering laparoscopic management of
endometriosis demonstrated that laparoscopy is
beneficial in treating endometriosis related pain at all
stages of the disease, although the best way to remove
lesions (excision or ablation) is unknown.
 Patient suffering from Chronic pain due to
endometriosis should be advised to under go second
look surgery to see whether 1 st surgery is effective or
recurrence of the disease and further management of
pain.
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29. 5 ) Pre ART
 IVF offers the highest pregnancy rates of
ART & is often used to treat women with
infertility associated with endometriosis.
 Pre ART Cyst excision / ablation may recur
within a short period OR Fibrosis and
adhesions may occur after peritoneal implant
cauterization --- Which might require second
look laparoscopy .
( Fertil Steril , 2010 )
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30. Frozen Pelvis ( 2nd look Scopy )
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31. ESHRE Guidelines
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32. found this quote from a book by Dr. Redwine
published in 2009 called
“100 Questions & Answers About Endometriosis:”
"Early second-look laparoscopy has been
found to decrease the ultimate amount of
adhesions. ”
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33. 33Dr. Shashwat JaniMob : 9909944160