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Endometriosis and Adhesions

What is a second look surgery, and why is it done?
A second look surgery is doing another planned surgery after a surgery. Second look laparoscopic surgeries have been done for decades to look into the abdomen for various reasons. Gynecology Oncologists (cancer surgeons) would do a second look after cancer surgery and chemotherapy to see how effective the treatment was. General surgeons often use a second look laparoscopy to evaluate the bowel after bowel has been deprived of oxygen, and appears to be necrotic. There are different times on when a second look laparoscopy is done, depending on what the desired plan is hoping to achieve. The second look laparoscopy that doctors do when dealing with pelvic pain/endometriosis, is to cut (lyse) any adhesions that have formed, or reformed, after cutting out (excising) endometriosis, or any type of surgery.Many surgeons do not feel that adhesions cause pain, unless there is complete or partial bowel obstruction, but having treated patients with pain for 30 years I realize adhesions are as bad as endometriosis, and at times worse, as a source of pain. Any injury to the body results in healing starting immediately. It doesn't matter if the injury is inside the abdomen, or outside the abdomen. Outside of the abdomen, we can see scarring, fibrotic tissue, and adhesions. Inside the abdomen, the healing process is the same, but we cannot see adhesions/fibrosis/scarring, unless inside the abdomen during surgery (there are times when adhesions can be visualized using imaging, but this is not common). The adhesions inside the abdomen can cause organs to stick to each other, making their normal function difficult. The sticking can cause pain with, or without, any movement. There can be bands of adhesions, and sometimes the bowel can be trapped in the bands, potentially causing obstruction. The surface of tissue can be come fibrotic (hard versus soft), and nerves can be trapped in this area. All of this has the potential to cause pain. Some adhesions may not cause pain, but it is difficult to determine which adhesions may be causing pain. Two decades ago, some of us did "awake laparoscopy" for pain mapping, and the results were surprising, but the amount of pain patients experienced made this procedure not very desirable. Many of us were able to determine that the patients with adhesions did have pain when the adhesions were manipulated. If adhesions are a source of pain, then preventing them is paramount after surgery. Accuracy and precision is key, and a discussion of that has been addressed in other posts. In my opinion, removing as little of normal tissue is important, but making sure that all of the disease process is removed. That is why I am not a proponent of TPE (total peritoneal excision). I feel that removing large areas of normal tissue may have adhesions form that may not have been necessary.The timing of the second look surgery is based on the healing process (click on the webpage below to see the wound healing graph). Once injury occurs, the process begins, and can take up to 6 months for the entire process to complete. Some of the early second look surgeries were performed on day 10 of the process, but the success in preventing adhesion formation/reformation was not very successful. Studies have been done to find the best time, and that seems to be between days 3-7 after surgery. This interrupts the primary healing process, so that the process cannot jump to the beginning, and start all over. How was it determined that there was some success by cutting adhesions during this time? A third look laparoscopy was performed, and 70 % of the patients did not form/reform adhesions. My data is about the same after hundreds of second look surgeries. Not every patient will form adhesions after surgery, but if they are formed, then they will not go away on their own. That does not mean they will cause pain, but if they do, then the pain is not going away on it’s own.Some patients think that the second look is to try and find more endometriosis, and that is not the purpose. The tissue is now so inflamed and unusual, because of the healing process, that endometriosis would not be visualized. It is only to cut adhesions.I have had patients ask about deep tissue massage to “break” the adhesions. If it is done in the time span of 3-7 days, then that could work, but most patients would not be able to tolerate the deep massage that soon after surgery. I always ask patients if they have a scar, and they really rub it vigorously, will that cause the scar to come apart? I doubt it, and I often demonstrate by rubbing a scar on my arm. Common sense has to play a role in medicine. We have even tried using inversion tables very soon after surgery to try and have gravity separate the tissue, but no success.Sadly, in spite of what we do, the body will still heal. There are other things we do during surgery that will help prevent the adhesions, such as barriers and suspending the ovaries, but I will post that at a later time. Doctors need to have a plan to try and prevent adhesions, and not just hope they will not form.

John Dulemba, M.D. Endometriosis Specialist at The Womens Centre

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