Surgical strategies to untangle a frozen pelvis
Few surgeries require the judgment, rigorous experience, and skill necessary to operate on a frozen pelvis
IN THIS ARTICLE
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:
- Solid grounding in pelvic anatomy, with live experience involving varying degrees of pelvic distortion
- A realistic expectation that the operation will be difficult and fraught with hazards
- Flexibility to change course when a particular pathway proves too risky
- Patience to take things as slowly as necessary.
Most important is a retroperitoneal approach—not to mention complete knowledge of the retroperitoneal spaces, where the structures that nourish and support the uterus and lymphatic system lie, as well as the ureters and rectum (FIGURE 1).
It may not be sufficient to learn the anatomy of the pelvis and the steps of the operation from an atlas of surgical technique; “real-life” findings can vary greatly from those described in a textbook. The surgeon needs ample experience to recognize the appearance and tactile characteristics of disease processes that afflict the female pelvis—and to know how to manage them.
FIGURE 1 Areolar tissue fills the pelvic spaces
The pelvic spaces contain areolar tissue and can be exposed by applying traction and deeply placed retractors.
This article describes the challenges posed by the frozen pelvis, so the surgeon can confront the condition with greater confidence and understanding. There is no substitute for hands-on experience, however. Do not begin the operation if you do not think you can complete it. Seek help beforehand, not during the procedure.
Undertake a multipronged diagnostic evaluation
The potential for a frozen pelvis, as well as its causes, can usually be identified by taking a careful history and documenting previous surgeries or pelvic problems (see “Five culprits: Which one is to blame?”).
The physical examination also can be revealing. Be alert for any anatomic changes apparent at the pelvic examination, which should include a rectovaginal assessment. If a lesion is palpated, attempt to define its size and determine whether it is fixed or mobile. Also asccertain whether the cul-de-sac is free, the uterus can be lifted out of the pelvis, and the disease process is predominantly uterine, adnexal, or involves adjacent organs. Although imaging studies may be useful, a careful pelvic examination may yield more practical information about potential difficulties.
Five culprits: Which one is to blame?
Five major causes of extensive pelvic disease lead to a frozen pelvis: infection, surgery, benign growths, malignant growths, and radiation therapy. When evaluating a patient, it is important to determine which of these conditions exist.
Infection. Adhesions and fibrosis secondary to infectious processes such as gonococcal salpingitis, tubo-ovarian abscess, a ruptured diverticulum, infected pelvic hematoma, and ruptured appendix can create anatomic abnormalities.
Surgery. The type of surgery a patient has undergone may provide important clues to potential problems. For example, pelvic distortion that arises from cesarean section and tubal reconstructive surgery differs considerably from that found in women who have undergone abdominal hysterectomy with preservation of one or both ovaries. Removal of a retained left ovary may require extensive dissection of the ureter and bowel.4
Benign and malignant growths. Uterine myomata, endometriosis, and adenomyosis are the most common benign growths that can lead to a frozen pelvis. Malignant growths of the adnexa, such as ovarian carcinoma, can necessitate en bloc resection of portions of the gastrointestinal tract along with the tumor. In contrast, carcinomas of the endometrium and cervix generally do not present with a frozen pelvis, although they occasionally require extensive or radical surgery.
Radiation therapy. When a woman has undergone radiation, pelvic structures are commonly adherent to the uterus and each other, making hysterectomy a challenge. The intestinal and urinary tracts also must be handled with great care. Even a small degree of intraoperative trauma to these structures can lead to postoperative complications including fistula formation.
Imaging studies—useful tool
Preoperative imaging can be of inestimable value. Pelvic ultrasonography,1 computed tomography, or magnetic resonance imaging may be worthwhile, as well as evaluation of the urinary and intestinal tracts. It is particularly important to learn preoperatively whether there is involvement of the ureters, bowel, and pelvic sidewalls.
Diagnostic laparoscopy may aid in planning the definitive surgery
When there is doubt about the extent of pelvic disease, diagnostic laparoscopy is a prudent way to assess the potential difficulties of surgery. The information it provides makes it possible to plan the definitive procedure and determine whether other specialists may be needed.
Other diagnostic steps, such as cystoscopy and sigmoidoscopy, can be performed at the time of diagnostic laparoscopy or postponed until the actual surgery.
Preparing for surgery
Level with the patient
Give the patient as much information as possible about potential problems with pelvic structures such as the ureters, bowel, and bladder. Also advise her that other surgeons may be called in to assist or to help repair damage to surrounding structures. In particular, counsel her about the very real possibility that a temporary diverting colostomy or ileostomy will be required. As usual, document details of these discussions in the record.
Bowel prep is imperative
In anticipation of possible enterolysis or intestinal tract surgery, all patients should undergo preoperative bowel preparation.
Consider ureteral catheterization
The possible need for preoperative ureteral catheterization should be discussed with a urologist, particularly if imaging reveals any significant ureteral deviation, fixation, constriction, or dilatation.
The use of catheters also helps the surgeon identify the ureters intraoperatively and may therefore prevent their injury.
Prepare for blood replacement
Advise the patient of the possible need for transfusion of red blood cells or other blood products during surgery. Whether it would be best to store her own blood (or that of a designated donor) or rely on the hospital blood bank depends on the circumstances of her case.
Insert a 3-way catheter
This precaution permits the instillation of retrograde dye intraoperatively to assess the integrity of the bladder.
Prophylactic anticoagulation and antibiotics? Absolutely
Postoperative wound infections and deep venous thrombosis, with the potential for life-threatening pulmonary embolization, are both significantly increased in patients who undergo pelvic surgery.2 The prophylactic use of antibiotics and blood thinners has been shown to reduce both complications and is strongly advised.
I prefer subcutaneous heparin because some newer agents, such as low-molecular-weight heparin, have been associated with significant postoperative bleeding.3
Choose an incision that guarantees broad exposure
The extreme care necessary during surgery in a frozen pelvis begins with the incision. If chosen wisely, it can help the surgeon avoid injury to the intestines upon abdominal entry.
In general, I prefer a vertical midline incision because it allows for maximum flexibility and exposure, particularly when used in conjunction with a Book-walter retractor. However, if the patient has had a prior paramedian or midline incision, extensive omental and intestinal adhesions are likely and can make entry difficult and increase the risk of intestinal injury. In such a case, an incision in a different location or direction may be wise.
For example, a transverse muscle-dividing incision may make it possible to find an area lateral to the original incision where the peritoneum, omentum, and intestinal tract are not adherent. Then, under direct vision, the incision can be extended and any adherent bowel near the midline incision can be safely dissected.
Once the fascia is incised, grasp it with a Kocher clamp. After entering the peritoneal cavity, include the peritoneum in the clamp. This allows for maximal traction during dissection of the bowel and omentum with scissors.
The most important action to take at the time of incision is to make it large enough to allow for excellent exposure.
An adequate incision and the appropriate retractor will minimize operative time and facilitate completion. The old adage that “wounds heal from side to side, not end to end” is particularly applicable.
First steps: Get oriented, assess adhesions
After entering the abdomen, identify pelvic structures and their location in relation to one another. In patients who have undergone previous surgery or had inflammatory disease, the omentum may be adherent to these structures. If the omental adhesions are filmy and easy to reduce, cut them free. However, if the omentum is densely adherent to the parietal peritoneum or other pelvic organs or bowel, it may be helpful to cut across the omentum, leaving a portion attached to the structures to be removed.
After omental or intestinal adhesions have been separated, move the small and large intestines up as far as possible from the pelvis and pack them away. Then identify the following pelvic structures: uterine fundus, round ligaments, infundibulopelvic (IP) ligaments, posterior cul-de-sac, anterior cul-de-sac, prevesical peritoneum, and pelvic brim. These structures may be difficult to recognize and to mobilize because of fibrosis and adhesions.
What to do if you get lost
At one time or another, every surgeon finds it necessary to rethink a planned procedure after the operation begins—a not uncommon scenario during surgery in the frozen pelvis. It can occur at the beginning of a procedure, once the incision is made and the pathology is surveyed, or it can arise when the surgeon is well into an operation, when all the usual landmarks are indistinguishable.
When the problem is clear from the get-go
When confronted with an impossible situation upon opening the abdomen, the surgeon has 2 options:
- close the abdomen and refer the patient
- call for the aid of a surgical colleague who has the necessary experience and skill.
When the operation is under way
This situation may not lend itself to so easy a solution. When the surgeon becomes overwhelmed by an unfamiliar operative field, he or she should stop operating, take stock of what has been accomplished and what remains to be done, check the status of the patient, and reevaluate the case. Again, 2 options are available:
- change the original goal and terminate the procedure at that point, scheduling reoperation for a later date
- call for help, particularly if arrangements have been made beforehand.
Either way, a compromised patient is too high a price to pay for the sake of the surgeon’s vanity, and the dictum of “primum non nocere” should become the guiding principle.
Once you have identified the structures, determine how you will be entering the retroperitoneum. This decision is important because the blood supply to the uterus and adnexa lies in the retroperitoneum, as do the ureters, which must be identified and kept under direct vision during ligation of the IP ligaments and dissection of the peritoneum around the uterus.
Retroperitoneal entry and elaboration of the retroperitoneal spaces are keys to the safe performance of a difficult hysterectomy or removal of retained adnexa in a patient with a frozen pelvis. The retroperitoneal approach makes it possible to reach around structures that are fixed in the pelvis, to identify the blood supply and other vital structures, and to proceed safely.