March 2007 · Vol. 19, No. 03Surgical strategies to untangle a frozen pelvis
Few surgeries require the judgment, rigorous experience, and skill necessary to operate on a frozen pelvis
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Fast Track
Malignant growths of the adnexa, such as ovarian carcinoma, can necessitate en bloc resection of portions of the GI tract along with the tumor
All patients should undergo preop bowel preparation because of the possible need for enterolysis or intestinal tract surgery
If the patient has had a paramedian or midline incision, extensive omental and intestinal adhesions are likely and can make entry difficult
Never assume you know the position of the ureter without confirming it
A history of surgery in the area of the bladder may leave it adherent or hard to separate from the cervix and vagina
To assess rectosigmoid integrity at the conclusion of the operation, insufflate the submersed rectosigmoid with air. Bubbles signify a breach in the bowel wall
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Donald
P.
Goldstein,
MD;
Professor, Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, and Founder and Co-director, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Boston Michael
J.
Callahan,
MDFellow in Gynecologic Oncology, Brigham and Women's Hospital, Boston
For a surgeon, the “frozen” pelvis can be as hazardous as the icy tundra that its name evokes: The reproductive organs and adjacent structures are distorted by extensive adhesive disease and fibrosis, which obscure the normal anatomic landmarks and surgical planes, making dissection extremely difficult and increasing the risk of damage to vital organs.
Despite these very real challenges, few training programs provide gynecologic residents with sufficient surgical experience to operate safely in this setting. The overall keys to success:
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