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Second-Look Surgery

Second-Look Surgery

Definition
Purpose
Description

Definition

Second-look surgery 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 surgery.

Purpose

Second-look surgery may be performed under numerous circumstances on patients with various medical conditions.

Cancer

A second-look procedure is sometimes performed to determine if a cancer patient has responded successfully to a particular treatment. Examples of cancers that are assessed during second-look surgery are ovarian cancer and colorectal cancer. In many cases, before a round of chemotherapy and/or radiation therapy is started, a patient will undergo a surgical procedure called cytoreduction to reduce the size of a tumor. This debulking increases the sensitivity of the tumor and decreases the number of necessary treatment cycles. Following cytoreduction and chemotherapy, a second-look procedure may be necessary to determine if the area is cancer-free.

An advantage to second-look surgery following cancer treatment is that if cancer is found, it may be removed during the procedure in some patients. In other cases, if a tumor cannot be entirely removed, the surgeon can debulk the tumor and improve the patient’s chances of responding to another cycle of chemotherapy. However, second-look surgery cannot definitively prove that a patient is free of cancer; some microscopic cancer cells can persist and begin to grow in other areas of the body. Even if no cancer is found during second-look surgery, the rate of cancer relapse is approximately 25%.

KEY TERMS

Adhesion— A band of internal scar tissue that develops after injury or surgery.

Anastomosis (plural, anastomoses)— The surgical connection of two structures, such as blood vessels or sections of the intestine.

Cholesteatoma— A destructive and expanding sac that develops in the middle ear or mastoid process.

Debulking— The removal of part of a malignant tumor in order to make the remainder more sensitive to radiation or chemotherapy.

Endometriosis— The growth of tissue like the lining of a woman’s uterus (endometrium) outside the uterus in other parts of the body.

Endoscopy— A surgical technique that uses an endoscope (a thin, lighted, telescope-like instrument) to visualize structures inside the human body.

Infertility— The inability to become pregnant or carry a pregnancy to term.

Ischemia— Inadequate blood supply to an organ or area of tissue due to obstruction of a blood vessel.

Kidney stones— Small solid masses that form in the kidney.

Pelvic disease

Second-look surgery may benefit patients suffering from a number of different conditions that affect the pelvic organs. Endometriosis is a condition in which the tissue that lines the uterus grows elsewhere in the body, usually in the abdominal cavity, leading to pain and scarring. Endometrial growths may be surgically removed or treated with medications. A second-look procedure may be performed following the initial surgery or course of medication to determine if treatment was successful in reducing the number of growths. Additional growths may be removed at this time.

Second-look surgery may also be performed following the surgical removal of adhesions (bands of scar tissue that form in the abdomen following surgery or injury) or uterine fibroids (noncancerous growths of the uterus). If the results are positive, an additional procedure may be performed to remove the adhesions or growths. Patients undergoing treatment for infertility may benefit from a second-look procedure to determine if the cause of infertility has been cured before ceasing therapy.

Abdominal disease

In patients suffering from bleeding from the gastrointestinal (GI) tract, recurrence of bleeding after attempted treatment remains a significant risk; approximately 10-25% of cases do not respond to initial treatment. Second-look surgery following treatment for GI bleeding may be beneficial in determining if bleeding has recurred and treating the cause of the bleeding before it becomes more extensive.

Patients suffering from a partial or complete blockage of the intestine are at risk of developing bowel ischemia (death of intestinal tissue due to a lack of oxygen). Initial surgery is most often necessary to remove the diseased segment of bowel; a second-look procedure is commonly performed to ensure that only healthy tissue remains and that the new intestinal connection (called an anastomosis) is healing properly.

Other conditions

A variety of other conditions can be assessed with second-look surgery. Patients who have undergone surgical repair of torn muscles in the knee might undergo a procedure called second-look arthroscopy to assess whether the repair is healing. A physician may use second-look mastoidoscopy to visualize the middle ear after removal of a cholesteatoma (a benign but destructive growth in the middle ear). A second endoscopic procedure may be performed on a patient who underwent endoscopic treatment for sinusitis (chronic infection of the sinuses) to evaluate the surgical site and remove debris.

Description

Second-look surgery may be performed within hours, days, weeks, or months of the initial procedure or treatment. This time interval depends on the patient’s condition and the type of procedure.

Laparotomy

A laparotomy is a large incision through the abdominal wall to visualize the structures inside the abdominal cavity. After placing the patient under general anesthesia, the surgeon first makes a large incision through the skin, then through each layer under the skin in the region that the surgeon wishes to explore. The area will be assessed for evidence of remaining disease. For example, in the case of second-look laparotomy following treatment for endometriosis, the abdominal organs will be examined for evidence of endometrial growths. In the case of cancer, a “washing” of the abdominal cavity may be performed; sterile fluid is instilled into the abdominal cavity and washed around the organs, then extracted with a syringe. The fluid is then analyzed for the presence of cancerous cells. Biopsies may also be taken of various abdominal tissues and analyzed.

If the surgeon discovers evidence of disease or a failed surgical repair, additional procedures may be performed to remove the disease or repair the dysfunction. For example, if adhesions are encountered during a second-look procedure on an infertile female patient, the surgeon may remove the adhesions at that time. Upon completion of the procedure, the incision is closed.

Laparoscopy

Laparoscopy is a surgical technique that permits a view of the internal abdominal organs without an extensive surgical incision. During laparoscopy, a thin lighted tube called a laparoscope is inserted into the abdominal cavity through a tiny incision. Images taken by the laparoscope are seen on a video monitor connected to the scope. The surgeon may then examine the abdominal cavity, albeit with a more limited operative view than with laparotomy. Procedures such as the removal of growths or repair of deformities can be performed by instruments inserted through other small incisions in the abdominal wall. After the procedure is completed, any incisions are closed with stitches.

Other procedures

Depending on the area of the body in question, other procedures may be used to perform second-look surgery. These include:

  • Arthroscopy. Arthroscopy uses a thin endoscope to visualize the inner space of a joint such as the knee or elbow. Second-look arthroscopy may be used to determine if previous surgery on the joint is healing properly.
  • Percutaneous nephrolithotomy (PNL). This minimally invasive procedure is used to remove kidney stones. Second-look PNL may be used to remove fragments of stones that could not be removed during the initial procedure.
  • Hysteroscopy. A hysteroscope is an instrument used to visualize and perform procedures on the inner cavity of the uterus. Second-look hysteroscopy may be used after surgery or medical treatment to treat adhesions or benign growths in the uterus to determine if they have been effectively removed.
  • Mastoidectomy. This surgical procedure is used to treat cholesteatoma; a second-look procedure is generally performed to ensure that the entire cholesteatoma was removed during the initial procedure.

Resources

BOOKS

Cushner, Fred D., W. Norman Scott, and Giles R. Scuderi, eds. Surgical Techniques for the Knee. New York: Thieme, 2005.

Hatch, Kenneth D. Laparoscopy for Gynecology and Oncology. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins Health, 2008.

Sabel, Michael S., Vernon K. Sondak, and Jeffrey J. Sussman, eds. Surgical Foundations: Essentials of Surgical Oncology. Philadelphia: Mosby Elsevier, 2007.

PERIODICALS

Ahn, J. H., J. C. Yoo, H. S. Yang, et al. “Second-Look Arthroscopic Findings of 208 Patients after ACL Reconstruction.” Knee Surgery, Sports Traumatology, Arthroscopy 15 (March 2007): 242–248.

Barakate, M., and I. Bottrill. “Combined Approach Tympanoplasty for Cholesteatoma: Impact of Middle-Ear Endoscopy.” Journal of Laryngology and Otology, June 7, 2007, 1–5.

Gershenson, D. M. “Management of Ovarian Germ Cell Tumors.” Journal of Clinical Oncology 25 (July 10, 2007): 2938–2943.

Marmo, Riccardo, Gianluca Rotandano, Maria Antonia Bianca, Roberto Piscopo, Antonio Prisco, and Livio Cipolletta. “Outcome of Endoscopic Treatment for Peptic Ulcer Bleeding: Is a Second Look Necessary?” Gastrointestinal Endoscopy 57, no. 1 (January 2003): 62–7.

Sood, A. K. “Second-Look Laparotomy for Ovarian Germ Cell Tumors: To Do or Not to Do?” Journal of Postgraduate Medicine 52 (October-December 2006): 246–247.

Yanar, H., K. Taviloglu, C. Ertekin, et al. “Planned Second-Look Laparoscopy in the Management of Acute Mesenteric Ischemia.” World Journal of Gastroenterology 13 (June 28, 2007): 3350–3353.

ORGANIZATIONS

American College of Surgeons. 633 N. Saint Clair St., Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org.

Society of Surgical Oncology. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. (847) 427-1400. http://www.surgonc.org.

OTHER

Horlbeck, Drew, and Matthew Ng. “Middle Ear Endoscopy.” eMedicine. June 12, 2006. [cited January 12, 2008] http://www.emedicine.com/ENT/topic483.htm.

Johnson, Darren L., and Jeffrey B. Selby. “Meniscal Transplantation: Indications and Results.” Medscape General Medicine, August 3, 2001. [cited May 20, 2003] http://www.medscape.com/viewarticle/408541_1.

Stephanie Dionne Sherk

Rebecca Frey, Ph.D.

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