role of 2nd look laparoscopy in endometriosis by dr shashwat jani

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 : [email protected]

Dr. Shashwat Jani 2Mob : 9909944160

Greetings From Ahmedabad …

May 2, 2023 Dr Shashwat Jani 9909944160 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


It’s very Frustrating … Women - No definitive cure. Physicians – Symptoms not correlating

with the extent of the disease.


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.


Indicated in…1 ) When there is recurrence of the disease.2 ) To see whether medical therapy is effective

or not3 ) When primary surgery was incomplete due

to advanced disease.4 ) When there is Chronic pelvic pain5 ) Before going for any major Assisted

reproductive technique.


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.


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.


• 4 yrs Recurrence rate :

• 24.6% Ovarian endometrioma.• 17.8% Pelvic endometriosis.• 30.6% Deep infiltrating disease.• 23.7% Ovarian + pelvic


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)


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


The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years.

(23 years follow up)


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.

May 2, 2023 Dr 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 )


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 EndometriosisGnRH Analogues


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 )


3 ) Second stage surgery

When primary surgery was incomplete, may be due to ….1 ) Advanced stage of disease2 ) unavailability of resources in Operative room3 ) Lack of expertise of surgeon4 ) Surgery abandoned due to Intraoperative

complication


“ Second look laparoscopy should be done in all above cases after medical therapy of 6 to 9 months .”


PubMed


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.


Recurrence & Problems

1.Impaired Quality of Life (Pain)

2.Infertility3.Endometrioma


Impaired QoL ( Pain )Mx

1.Second Laparoscopy Surgery2.Medical Suppression3.Expectant Management


Impaired QoLSecond Laparoscopy Surgery

• Re-Excision• Pelvic Denervations

–Presacral Neurectomy–LUNA

• Hysterectomy


Repetetive Surgery for Pelvic Pain

Berlando N, Curr Opin Obstet Gynecol 2010,

2nd Surgery 3rd Surgery

May 2, 2023

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.


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.


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 )


Frozen Pelvis ( 2nd look Scopy )


ESHRE Guidelines


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. ”

Dr. Shashwat Jani 33Mob : 9909944160

Thank you

role of 2nd look laparoscopy in endometriosis by dr shashwat jani

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