Second-look surgery
Re-operation after incomplete surgery elsewhere. Bring your operative reports and we'll tell you honestly what we see.
A significant part of our practice is patients who have already had surgery that did not help. Sometimes disease was left behind; sometimes the original operation was appropriate and the pain has another cause. We will tell you which, including when the answer means we should not operate.
Working out what actually happened
The first thing is to establish what was done, and in what order. Where there have been several operations across several years there have usually been other things running alongside them: medications started and stopped, life events, symptoms that changed. Some of that is obvious and some of it is not, and the context matters as much as the operative notes do.
Then we put that against the symptoms you have now, and do something that sounds slightly odd. We look at you as though you had never been operated on at all, and ask what we would think. Then we put the two readings together.
What usually emerges is more mixed than people expect. Some of what was done did help. Something else changed, sometimes for the worse, and sometimes it changed the shape of the symptoms rather than the amount of them.
A second look, or a completion
Where a previous operation was partial, we can often see exactly what was done and where it stopped. The work is then to tidy up what is there and extend it to finish the job.
That is why we tend to think of these as completion procedures as much as second looks. It is usually less a matter of starting again than of finishing something.
Is it the endometriosis that is still hurting?
A large part of this is looking carefully at the symptoms and working out whether what you are describing is endometriosis, adenomyosis, or something else altogether.
Very often it is adenomyosis, and the muscle spasm that builds up around the disease. Sometimes that is the dominant part of what you are feeling. It needs treating in its own right, and identifying it is as much a part of the job as the surgery is.
Whether another operation is the answer
Sometimes it plainly is. The answers to certain questions make it clear that there is still work to be done, and then it becomes a question of what that work looks like and when it should happen.
Sometimes other things need to happen first. Medication, or physical therapy, either to buy time or to put you in better shape to recover from an operation later on. The order is part of the plan rather than an afterthought.
What is different about operating twice
We need to know what was done, where, and what difference it made. Sometimes there are adhesions. Sometimes the anatomy is distorted. A partial operation can leave inflammation behind, and that causes scarring later which has to be dealt with in its turn.
It does not necessarily change the work, though. Treating endometriosis means removing the disease and removing the scarring and injury the disease has caused, so a good deal of the job is already fixing the same kinds of things that surgery itself can leave behind. It can take longer. It rarely changes what needs doing.
When the first operation was good and you still hurt
Sometimes the honest answer is that the surgery was genuinely good, and what is left is muscle spasm or adenomyosis. Those are hard conversations, because people expected an operation to fix everything. What it often did was open the door for those other things to be treated successfully.
And sometimes an operation was done well and the result still was not what anyone expected. This has happened to my own patients. You remove the disease, you are satisfied with the work, and the bowel symptoms are no better.
When that happens you have to think about it hard. What you often find is that the work was good but something small is getting in the way. A scar. A small amount of disease left behind. Fixing that one thing, specifically, can unlock the success of the whole previous operation. I have had a patient I operated on myself who did not feel better afterwards, and there was simply a scar. As soon as it was fixed they were brilliant.
That comes back to how endometriosis behaves. We do not understand all of it, but a great deal of it is physical and mechanical. If there is something in the body causing a problem, and you make that better, it should make a difference.
What you can expect
Once we know what has been done and what still needs doing, we can give you an honest reading of what we see and what we think can be improved. That includes the parts that are not surgical, because the adenomyosis and the muscle spasm usually have to be managed alongside anything we operate on.
Mostly it comes down to sequence. One thing often has to happen before another for any of it to work, and the right order is different for different people.
What you should get is a detailed picture with the uncertainty left in rather than taken out. Not a promise, but enough perspective to decide with.