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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
Mob : 9909944160 Dr. Shashwat Jani 2
Greetings From Ahmedabad …
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
20-Jan-16 3Dr Shashwat Jani 9909944160
20-Jan-16 Dr Shashwat Jani 9909944160 4
It’s very Frustrating …
 Women - No definitive cure.
 Physicians – Symptoms not correlating with
the extent of the disease.
20-Jan-16 5Dr Shashwat Jani 9909944160
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.
20-Jan-16 6Dr Shashwat Jani 9909944160
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.
20-Jan-16 7Dr Shashwat Jani 9909944160
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.
20-Jan-16 8Dr Shashwat Jani 9909944160
 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.
20-Jan-16 9Dr Shashwat Jani 9909944160
• 4 yrs Recurrence rate :
• 24.6% Ovarian endometrioma.
• 17.8% Pelvic endometriosis.
• 30.6% Deep infiltrating disease.
• 23.7% Ovarian + pelvic
20-Jan-16 10Dr Shashwat Jani 9909944160
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)
20-Jan-16 11Dr Shashwat Jani 9909944160
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
20-Jan-16 12Dr Shashwat Jani 9909944160
The reported recurrence rate was high,
estimated as 21.5% at 2 years and
40-50% at 5 years.
(23 years follow up)
20-Jan-16 13Dr Shashwat Jani 9909944160
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.
20-Jan-16 14Dr Shashwat Jani 9909944160
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
 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
20-Jan-16 16Dr Shashwat Jani 9909944160
 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 )
20-Jan-16 17Dr Shashwat Jani 9909944160
20-Jan-16 Dr Shashwat Jani 9909944160 18
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
20-Jan-16 19Dr Shashwat Jani 9909944160
“ Second look laparoscopy
should be done in all above cases
after medical therapy of 6 to 9
months .”
20-Jan-16 20Dr Shashwat Jani 9909944160
PubMed
20-Jan-16 Dr Shashwat Jani 9909944160 21
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.
20-Jan-16 22Dr Shashwat Jani 9909944160
Recurrence & Problems
1.Impaired Quality of Life
(Pain)
2.Infertility
3.Endometrioma
20-Jan-16 23Dr Shashwat Jani 9909944160
Impaired QoL ( Pain )
Mx
1.Second Laparoscopy Surgery
2.Medical Suppression
3.Expectant Management
20-Jan-16 24Dr Shashwat Jani 9909944160
Impaired QoL
Second Laparoscopy Surgery
• Re-Excision
• Pelvic Denervations
–Presacral Neurectomy
–LUNA
• Hysterectomy
20-Jan-16 25Dr Shashwat Jani 9909944160
Repetetive Surgery for Pelvic Pain
Berlando N, Curr Opin Obstet Gynecol 2010,
2nd Surgery 3rd Surgery
20-Jan-16 26Dr Shashwat Jani 9909944160
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.
20-Jan-16
 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.
20-Jan-16 28Dr Shashwat Jani 9909944160
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 )
20-Jan-16 29Dr Shashwat Jani 9909944160
Frozen Pelvis ( 2nd look Scopy )
20-Jan-16 Dr Shashwat Jani 9909944160 30
ESHRE Guidelines
20-Jan-16 31Dr Shashwat Jani 9909944160
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. ”
20-Jan-16 32Dr Shashwat Jani 9909944160
33Dr. Shashwat JaniMob : 9909944160
ROLE OF 2nd LOOK LAPAROSCOPY IN ENDOMETRIOSIS BY DR SHASHWAT JANI

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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 20-Jan-16 3Dr Shashwat Jani 9909944160
  • 4. 20-Jan-16 Dr Shashwat Jani 9909944160 4
  • 5. It’s very Frustrating …  Women - No definitive cure.  Physicians – Symptoms not correlating with the extent of the disease. 20-Jan-16 5Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16 6Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16 7Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16 8Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16 9Dr Shashwat Jani 9909944160
  • 10. • 4 yrs Recurrence rate : • 24.6% Ovarian endometrioma. • 17.8% Pelvic endometriosis. • 30.6% Deep infiltrating disease. • 23.7% Ovarian + pelvic 20-Jan-16 10Dr Shashwat Jani 9909944160
  • 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) 20-Jan-16 11Dr Shashwat Jani 9909944160
  • 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 20-Jan-16 12Dr Shashwat Jani 9909944160
  • 13. The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. (23 years follow up) 20-Jan-16 13Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16 14Dr Shashwat Jani 9909944160
  • 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 20-Jan-16 16Dr Shashwat Jani 9909944160
  • 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 ) 20-Jan-16 17Dr Shashwat Jani 9909944160
  • 18. 20-Jan-16 Dr Shashwat Jani 9909944160 18
  • 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 20-Jan-16 19Dr Shashwat Jani 9909944160
  • 20. “ Second look laparoscopy should be done in all above cases after medical therapy of 6 to 9 months .” 20-Jan-16 20Dr Shashwat Jani 9909944160
  • 21. PubMed 20-Jan-16 Dr Shashwat Jani 9909944160 21
  • 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. 20-Jan-16 22Dr Shashwat Jani 9909944160
  • 23. Recurrence & Problems 1.Impaired Quality of Life (Pain) 2.Infertility 3.Endometrioma 20-Jan-16 23Dr Shashwat Jani 9909944160
  • 24. Impaired QoL ( Pain ) Mx 1.Second Laparoscopy Surgery 2.Medical Suppression 3.Expectant Management 20-Jan-16 24Dr Shashwat Jani 9909944160
  • 25. Impaired QoL Second Laparoscopy Surgery • Re-Excision • Pelvic Denervations –Presacral Neurectomy –LUNA • Hysterectomy 20-Jan-16 25Dr Shashwat Jani 9909944160
  • 26. Repetetive Surgery for Pelvic Pain Berlando N, Curr Opin Obstet Gynecol 2010, 2nd Surgery 3rd Surgery 20-Jan-16 26Dr Shashwat Jani 9909944160
  • 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. 20-Jan-16
  • 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. 20-Jan-16 28Dr Shashwat Jani 9909944160
  • 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 ) 20-Jan-16 29Dr Shashwat Jani 9909944160
  • 30. Frozen Pelvis ( 2nd look Scopy ) 20-Jan-16 Dr Shashwat Jani 9909944160 30
  • 31. ESHRE Guidelines 20-Jan-16 31Dr Shashwat Jani 9909944160
  • 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. ” 20-Jan-16 32Dr Shashwat Jani 9909944160
  • 33. 33Dr. Shashwat JaniMob : 9909944160

Editor's Notes

  1. BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.