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Second-look and second surgery: second chance or second best?

About 40 years ago, second-look laparotomy (SLL) was introduced to evaluate, surgically and pathologically, primary treatment in case a clinical complete remission was obtained in ovarian cancer patients. But does SLL increase the disease-free or overall survival? Important technical aspects of the procedure as: how many biopsies should be taken, can laparoscopy be replaced by laparotomy and should complete lymphadnectomy be performed at SLL, are still not clarified. This and maybe even more important issues, are disputed in literature: for instance, should a SLL be done at all, or should a SLL be performed in order to do a secondary cytoreduction in case tumour is found at the operation. If clinical remission is reached in more than 50% of the patients with advanced disease, tumour still can be found at SLL. If no tumour is found at SLL, macroscopically or microscopically, the operation is redundant. Apart from this, the recurrence rate after such a "negative SLL" is about 35%. Whether tumour found at SLL should be removed will depend on the fact if the tumour still is responsive to chemotherapy. To minimise the chance of tumour resistance, secondary surgery should be done as early as possible during treatment. Therefore, an interval debulking will be the intervention of choice. So, as long as there is no evidence that SLL increases the survival in ovarian cancer patients, it should be done in a research setting only. Also, the usefulness of secondary surgery for recurrent disease mainly depends on the chemo-sensitivity of the tumour. After a complete remission, which lasts for more than a year, complete secondary cytoreduction, again followed by chemotherapy, improves survival.