Second-look and third-look

What is "second look" and "third look" laparoscopy for adhesions?


The principle of SSL was first introduced by Swolin to evaluate the result of some surgical procedures. 

This principle soon became a routine used by many gynecological surgeons and investigators allowing a chance to perform adhesiolysis for the de novo or recurrent adhesions encountered during SLL. 

Dr. Daniel Kruschinski is one of the very few surgeons in the world, who performs a second look laparoscopy (SLL) about seven days after the initial surgical procedure. 

In Dr. Kruschinski's experience the risk of adhesions resulting in the need for a subsequent surgery is greatly reduced. 

He has mastered the required advanced microsurgical laparoscopic techniques and has logged thousands of hours in performing very difficult, time-consuming, risky surgical procedures. 

Repeat surgery for adhesions in these cases is usually less extensive and does not usually involve the same amount of dissection that led to the formation of adhesions in the first place. 

The same was shown by Jansen, who reported that second-look laparoscopy resulted in a significant reduction in adhesions at the time of a "third-look laparoscopy". 

Trimbos-Kemper reported a reduction in the incidence of ectopic pregnancy in women who had undergone SLL, although the intrauterine pregnancy rate was unchanged. 

Surry and colleagues reported a 52.1% intrauterine pregnancy in 31 patients who had undergone early SLL after reconstructive pelvic surgery. 

Other potential advantages of second-look laparoscopy include the ability of the surgeon to assess the efficacy of surgical techniques or adjuvants, as well as to provide the patient a reasonable assessment of likely prognosis. 

If the patient is among the approximately ten percent of subjects in whom adhesions worsen, that patient may benefit from early referral to ART as opposed to protracted lengths of time spent trying to conceive against very long odds. 


Dr Kruschinski offers a third look laparoscopy to patients whom are symptomatic even after 3 months of second look laparoscopy. 

Surgeon sees an improvement of the adhesion score as a success, whereas the patient often sees an improvement of symptoms or a complete disappearance of symptoms as a success! 

After surgery some adhesions may return, the surgeon might measure the reduction of adhesions as an improvement while the patient says s(h)e has pain and therefore concludes the adhesions are back! 

In some cases there may be a huge improvement of adhesions (by 90%), but some small adhesions might have formed somewhere and cause extreme pain. 

Hence , a third look laparoscopy will help identify these small adhesions but which cause symptoms and will most importantly treat them. 

Trimbos-Kemper and co-workers went to further "third-look laparoscopy" in patients who had undergone an early second-look procedure with adhesiolysis at that time. They reported that more than half of the adhesions that were separated at the second-look laparoscopic procedure did not recur.