SURGICAL TECHNIQUES

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

The author reports no fi nancial relationships relevant to this article.

In a frozen pelvis, the vesical space can be developed by incising the peritoneum of the avascular layer of ® Dowden Health Mediathe anterior broad between the divided round . Bodell Scott Copyright © SurgicalFor personal strategies use only to untangle a frozen pelvis IN THIS ARTICLE ❙ What to do Few require the judgment, rigorous if you get lost experience, and skill necessary to operate on Page 65 a frozen pelvis ❙ Choose entry into or a surgeon, the “frozen” pel- ing degrees of pelvic distortion the retroperitoneum vis can be as hazardous as the • A realistic expectation that the opera- with care Ficy tundra that its name evokes: tion will be diffi cult and fraught with Page 66 The reproductive organs and adjacent hazards ❙ Freeing the bladder structures are distorted by extensive • Flexibility to change course when a adhesive disease and fi brosis, which ob- particular pathway proves too risky can be diffi cult scure the normal anatomic landmarks • Patience to take things as slowly as Page 69 and surgical planes, making dissection necessary. extremely diffi cult and increasing the Most important is a retroperitoneal risk of damage to vital organs. approach—not to mention complete Despite these very real challenges, knowledge of the retroperitoneal spac- few training programs provide gyneco- es, where the structures that nourish logic residents with suffi cient surgical ex- and support the and lymphatic perience to operate safely in this setting. system lie, as well as the ureters and rec- The overall keys to success: tum (FIGURE 1, page 64). • Solid grounding in pelvic anatomy, It may not be suffi cient to learn the with live experience involving vary- anatomy of the pelvis and the steps of the

62 OBG MANAGEMENT • March 2007

For mass reproduction, content licensing and permissions contact Dowden Health Media. Five culprits: Which one is to blame?

ive major causes of extensive pelvic Benign and malignant growths. disease lead to a frozen pelvis: Uterine myomata, , and ad- F infection, , benign growths, enomyosis are the most common benign malignant growths, and radiation therapy. growths that can lead to a frozen pelvis. When evaluating a patient, it is important to Malignant growths of the adnexa, such as determine which of these conditions exist. ovarian carcinoma, can necessitate en bloc Infection. Adhesions and fi brosis resection of portions of the gastrointesti- secondary to infectious processes such nal tract along with the tumor. In contrast, as gonococcal salpingitis, tubo-ovarian carcinomas of the and abscess, a ruptured diverticulum, infected generally do not present with a frozen pelvic hematoma, and ruptured appendix pelvis, although they occasionally require can create anatomic abnormalities. extensive or radical surgery. Surgery. The type of surgery a patient Radiation therapy. When a woman has undergone may provide important clues has undergone radiation, pelvic structures to potential problems. For example, pelvic are commonly adherent to the uterus distortion that arises from cesarean sec- and each other, making tion and tubal reconstructive surgery differs a challenge. The intestinal and urinary considerably from that found in women who tracts also must be handled with great have undergone abdominal hysterectomy care. Even a small degree of intraopera- with preservation of one or both . Re- tive trauma to these structures can lead moval of a retained left may require ex- to postoperative complications including tensive dissection of the ureter and bowel.4 fi stula formation. operation from an atlas of surgical tech- The physical examination also can nique; “real-life” fi ndings can vary greatly be revealing. Be alert for any anatomic from those described in a textbook. The changes apparent at the pelvic examina- surgeon needs ample experience to rec- tion, which should include a rectovagi- FAST TRACK ognize the appearance and tactile char- nal assessment. If a lesion is palpated, Malignant growths acteristics of disease processes that affl ict attempt to defi ne its size and determine the female pelvis—and to know how to whether it is fi xed or mobile. Also as- of the adnexa, manage them. certain whether the cul-de-sac is free, such as ovarian This article describes the challenges the uterus can be lifted out of the pelvis, carcinoma, can posed by the frozen pelvis, so the surgeon and the disease process is predominantly necessitate en bloc can confront the condition with greater uterine, adnexal, or involves adjacent or- confi dence and understanding. There is no gans. Although imaging studies may be resection of portions substitute for hands-on experience, how- useful, a careful pelvic examination may of the GI tract along ever. Do not begin the operation if you do yield more practical information about with the tumor not think you can complete it. Seek help potential diffi culties. beforehand, not during the procedure. Imaging studies—useful tool Preoperative imaging can be of inesti- Undertake a multipronged mable value. Pelvic ultrasonography,1 diagnostic evaluation computed tomography, or magnetic res- The potential for a frozen pelvis, as well onance imaging may be worthwhile, as as its causes, can usually be identifi ed by well as evaluation of the urinary and in- taking a careful history and document- testinal tracts. It is particularly important ing previous surgeries or pelvic prob- to learn preoperatively whether there is lems (see “Five culprits: Which one is to involvement of the ureters, bowel, and blame?” above). pelvic sidewalls. CONTINUED

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FIGURE 1 Consider ureteral catheterization Areolar tissue fi lls the pelvic spaces The possible need for preoperative ure- teral catheterization should be discussed with a urologist, particularly if imaging Space of Retzius reveals any signifi cant ureteral deviation, fi xation, constriction, or dilatation. Paravesical space The use of catheters also helps the sur- Vesicovaginal space geon identify the ureters intraoperatively and may therefore prevent their injury.

Retrovaginal space Prepare for blood replacement Pararectal space Advise the patient of the possible need Cox Presacral space for transfusion of red blood cells or other Birck

© blood products during surgery. Whether it would be best to store her own blood The pelvic spaces contain areolar tissue and can be exposed by applying traction and deeply (or that of a designated donor) or rely on placed retractors. the hospital blood bank depends on the circumstances of her case. Diagnostic may aid in planning the defi nitive surgery Insert a 3-way catheter When there is doubt about the extent of This precaution permits the instillation of pelvic disease, diagnostic laparoscopy retrograde dye intraoperatively to assess is a prudent way to assess the potential the integrity of the bladder. diffi culties of surgery. The information it provides makes it possible to plan the de- Prophylactic anticoagulation fi nitive procedure and determine whether and antibiotics? Absolutely other specialists may be needed. Postoperative wound infections and deep Other diagnostic steps, such as cystos- venous thrombosis, with the potential for FAST TRACK copy and sigmoidoscopy, can be performed life-threatening pulmonary embolization, All patients should at the time of diagnostic laparoscopy or are both signifi cantly increased in pa- postponed until the actual surgery. tients who undergo pelvic surgery.2 The undergo preop prophylactic use of antibiotics and blood bowel preparation thinners has been shown to reduce both because of the Preparing for surgery complications and is strongly advised. possible need for Level with the patient I prefer subcutaneous heparin because Give the patient as much information as some newer agents, such as low-molecu- enterolysis or possible about potential problems with lar-weight heparin, have been associated intestinal tract pelvic structures such as the ureters, bow- with signifi cant postoperative .3 surgery el, and bladder. Also advise her that other surgeons may be called in to assist or to help repair damage to surrounding struc- Choose an incision that tures. In particular, counsel her about guarantees broad exposure the very real possibility that a temporary The extreme care necessary during sur- diverting colostomy or ileostomy will be gery in a frozen pelvis begins with the required. As usual, document details of incision. If chosen wisely, it can help the these discussions in the record. surgeon avoid injury to the intestines upon abdominal entry. Bowel prep is imperative In general, I prefer a vertical midline

In anticipation of possible enterolysis or incision because it allows for maximum Cox

intestinal tract surgery, all patients should fl exibility and exposure, particularly Birck

undergo preoperative bowel preparation. when used in conjunction with a Book- Images:

64 OBG MANAGEMENT • March 2007 What to do if you get lost

t one time or another, every When the operation is under way surgeon fi nds it necessary to This situation may not lend itself to so easy Arethink a planned procedure after a solution. When the surgeon becomes the operation begins—a not uncommon overwhelmed by an unfamiliar operative scenario during surgery in the frozen pelvis. fi eld, he or she should stop operating, take It can occur at the beginning of a procedure, stock of what has been accomplished and once the incision is made and the pathology what remains to be done, check the status is surveyed, or it can arise when the of the patient, and reevaluate the case. surgeon is well into an operation, when all Again, 2 options are available: the usual landmarks are indistinguishable. • change the original goal and terminate the procedure at that point, scheduling When the problem is clear reoperation for a later date from the get-go • call for help, particularly if arrangements When confronted with an impossible have been made beforehand. situation upon opening the abdomen, the Either way, a compromised patient is too surgeon has 2 options: high a price to pay for the sake of the • close the abdomen and refer the patient surgeon’s vanity, and the dictum of “primum • call for the aid of a surgical colleague who non nocere” should become the guiding has the necessary experience and skill. principle. walter retractor. However, if the patient First steps: Get oriented, has had a prior paramedian or midline assess adhesions incision, extensive omental and intestinal After entering the abdomen, identify adhesions are likely and can make entry pelvic structures and their location in diffi cult and increase the risk of intestinal relation to one another. In patients who injury. In such a case, an incision in a dif- have undergone previous surgery or had ferent location or direction may be wise. infl ammatory disease, the omentum may FAST TRACK For example, a transverse muscle-di- be adherent to these structures. If the If the patient has viding incision may make it possible to omental adhesions are fi lmy and easy fi nd an area lateral to the original incision to reduce, cut them free. However, if the had a paramedian where the peritoneum, omentum, and in- omentum is densely adherent to the pari- or midline incision, testinal tract are not adherent. Then, un- etal peritoneum or other pelvic organs or extensive omental der direct vision, the incision can be ex- bowel, it may be helpful to cut across the and intestinal tended and any adherent bowel near the omentum, leaving a portion attached to midline incision can be safely dissected. the structures to be removed. adhesions are likely Once the fascia is incised, grasp it and can make entry with a Kocher clamp. After entering the Identify landmarks diffi cult peritoneal cavity, include the peritoneum After omental or intestinal adhesions in the clamp. This allows for maximal have been separated, move the small and traction during dissection of the bowel large intestines up as far as possible from and omentum with scissors. the pelvis and pack them away. Then The most important action to take identify the following pelvic structures: at the time of incision is to make it large uterine fundus, round ligaments, infun- enough to allow for excellent exposure. dibulopelvic (IP) ligaments, posterior An adequate incision and the appropri- cul-de-sac, anterior cul-de-sac, prevesi- ate retractor will minimize operative time cal peritoneum, and pelvic brim. These and facilitate completion. The old adage structures may be diffi cult to recognize that “wounds heal from side to side, not and to mobilize because of fi brosis and end to end” is particularly applicable. adhesions. CONTINUED

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FIGURE 2 the dissection caudad allows entry into Transect the round ligaments the retrovesical space and into areas of the broad ligament adjacent to the uterus. This approach also makes it possible to produce traction on the peritoneum and facilitate separation of the areolar tissue between the bladder and cervix to enter the vesicovaginal space. Continue dissec- tion of the bladder from the cervix and by operating from one side of the pelvis to the other.

The ureter, a surgeon’s nemesis Never assume you know the position of the ureter without confi rming it; a major To facilitate entry into the retroperitoneum, transect the round ligaments. Then develop the deviation of its course can occur second- retroperitoneal spaces using blunt dissection. ary to pathologic processes in the pelvis. The ureter can be identifi ed by direct visu- Choose entry into the alization, peristalsis, and palpation. If it is retroperitoneum with care rolled between the thumb and forefi nger, Once you have identifi ed the structures, the ureter produces a snapping sensation. determine how you will be entering the After entering the retroperitoneum, retroperitoneum. This decision is impor- identify the ureter between the pelvic tant because the blood supply to the uter- brim and Wertheim’s tunnel. Although it us and adnexa lies in the retroperitoneum, may, at times, be seen through the thin as do the ureters, which must be identifi ed peritoneum as it travels over the common FAST TRACK and kept under direct vision during liga- iliac artery down into the pelvis, the ure- Never assume you tion of the IP ligaments and dissection of ter is generally not clearly visualized in the peritoneum around the uterus. the frozen pelvis and may become appar- know the position Retroperitoneal entry and elaboration ent only after the peritoneum has been of the ureter without of the retroperitoneal spaces are keys to opened and the retroperitoneal spaces confi rming it the safe performance of a diffi cult hyster- elaborated. ectomy or removal of retained adnexa in a Near the level of the pelvic brim on patient with a frozen pelvis. The retroperi- the left side of the body, the ureter will toneal approach makes it possible to reach be closer to the IP ligament than it is on around structures that are fi xed in the pel- the right side, due to the location of the vis, to identify the blood supply and other sigmoid colon and its mesentery on the vital structures, and to proceed safely. left side, which elevate the ureter in the Several entry sites are possible. In the ventral direction. frozen pelvis, I believe the round ligament Once the ureter has been identi- is the ideal location. Identify and divide fi ed, leave it attached to the peritoneum this ligament as it enters the internal ring, as much as possible. When the ureter is and incise the peritoneum cephalad along adherent to pelvic pathology, lateral- the course of the IP ligaments (FIGURE 2). ize it from the medial leaf of the broad Next, open the pararectal space to vi- ligament as far down into the pelvis as sualize the iliac vessels and ureter, which necessary to allow complete removal of can be identifi ed on the medial leaf of the the peritoneum along with the pathology. peritoneum. The IP ligaments can then be The extent of dissection necessary will visualized and safely divided. Extending vary with the pathology. CONTINUED

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Handle the ureter gently FIGURE 3 Never handle the ureter excessively or Incise the broad-ligament unnecessarily. When it is dissected free, peritoneum let it lie free rather than retracting it with umbilical tapes or Penrose drains, which can slide up and down, damaging the vas- culature that lies in the adventitia of the ureteral wall.

Freeing the bladder can be diffi cult A history of surgery in the area of the bladder, such as cesarean section or blad- der advancement with uterine suspen- sion, may leave the bladder adherent to or hard to separate from the cervix and vagina. Normally, the vesicouterine peri- toneum is fl exible, mobile, and easy to free from the cervix and vagina. A history of disease processes such as endometrio- Incise the peritoneum of the avascular layer of the anterior broad ligament bilaterally between the divided round liga- sis, infection, or tumors makes this dis- ments to develop the vesical space bilaterally. One way to section diffi cult, with a real risk of inad- do this is to gently tease away the areolar tissue using a fi n- ger, pushing the tissue medially. Then divide the peritoneum vertent cystotomy. between the 2 spaces and sweep the bladder off the cervix One technique to make this dissec- using blunt or sharp dissection. tion easier and safer is to enter the ret- roperitoneum laterally near the round sacral ligaments, posteriorly by the rectum ligament. In this location, the bladder and sacrum, and caudally by the vagina— may not have been involved in the prior but these relationships are usually lost in FAST TRACK dissection, and the tissue may be more the frozen pelvis. Extensive infl ammatory A history of surgery areolar and less dense than it is in the disease, tumors of the tubes and ovaries, midline. After entering the retroperito- extensive pelvic endometriosis, and prior in the area of the neum, elevate the bladder by incising infection due to a diverticular abscess or bladder may leave the vesicouterine peritoneum trans- ruptured appendix can obscure the nor- it adherent or hard versely. By rolling a fi nger or an instru- mal confi nes of the cul-de-sac. It can also to separate from the ment cephalad in the anterior leaf of be obliterated by large myomas, which the broad ligament, the bladder can be can fi ll the pelvic cavity and extend up- cervix and vagina sharply separated from the cervix. ward beyond the sacral promontory into When the bladder is densely adher- the abdominal cavity, thereby displacing ent, make an incision into its dome away the intestines and creating potential de- from the cervix to visualize the interior viation and compression of the ureters. of the bladder. Place the index fi nger into Freeing the peritoneal attachments the bladder to identify its refl ection, and both anteriorly and posteriorly, as well as cut through the dense adhesions between at the sides of the pelvis, may release the it and the cervix and vagina (FIGURE 3). pelvic contents and allow elevation of the uterus into the abdominal cavity. Then the ureter, uterine vasculature, and sup- Cul-de-sac of Douglas porting ligaments can be identifi ed. Dis- may be hard to recognize section becomes simpler after this point. In a disease-free pelvis, the posterior cul- However, when the rectum and ure- de-sac is bounded laterally by the utero- ters are densely adherent, as they often

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FIGURE 4 steps, and a temporary colostomy can be Mobilize the uterus avoided. Bowel resection may be neces- sary if the bowel has sustained damage. If bowel injury is suspected, irrigate the bowel through the rectum with sterile milk or dye solution using a Foley cathe- ter with a 30-cc bag. Another widely used option to assess rectosigmoid integrity is to insuffl ate the submersed rectosigmoid with air. Bubbles signal a breach in the integrity of the bowel wall.

Postoperative care After surgery, the principles of early mobilization and ambulation are key. The single most important postopera- tive intervention is early ambulation, which can minimize pulmonary prob-

To free the uterus from its posterior visceral attachments lems, ileus, bladder atony, and throm- and render it mobile, develop the rectovaginal space. boembolic disease secondary to deep venous thrombosis. are in the frozen pelvis, dissection can be- To protect against venous thrombo- come diffi cult, with a real danger of rectal embolic disease, use pneumatic compres- perforation. A basic principle in any hys- sion devices and early ambulation. In terectomy is to hug the uterus as closely women with other risk factors for deep as possible, staying near the posterior sur- venous thrombosis, such as malignancy, face of the uterus and cervix using both diabetes, obesity, and smoking, consider FAST TRACK blunt and sharp dissection. This eventu- subcutaneous heparin. To assess recto- ally makes it possible to fi nd a reasonable Unless the bowel was resected or plane to enter the rectovaginal space at the extensive adhesiolysis was performed, I sigmoid integrity superior portion of the cul-de-sac between generally allow the patient to have clear at the conclusion the uterosacral ligaments. liquids on the fi rst postoperative day. I of the operation, The tissue below this level is not usu- then advance oral intake after gastroin- insuffl ate the sub- ally involved in the frozen pelvis and will testinal motility returns or when the pa- give way readily once the uterosacral lig- tient complains of hunger. mersed rectosigmoid aments are divided. It is unnecessary to Remove the urethral catheter on the with air. Bubbles operate beyond this level to any great ex- fi rst postoperative day unless cystotomy signify a breach in tent because the surgery already extends or extensive dissection of the ureters or distal to the cervicovaginal junction. In bladder was performed. ■ the bowel wall some circumstances, it may be necessary to enter the vagina anteriorly to defi ne References the relationship between the posterior 1. Willson JR. Ultrasonography in the diagnosis of gyneco- logic disorders. Am J Obstet Gynecol. 1991;160:1064– cervix and adherent bowel (FIGURE 4). 1071. 2. Polk HC Jr. Continuing refi nements in surgical antibi- otic prophylaxis. Arch Surg. 2005;140:1066–1067. Identifying and repairing 3. Fejgin MD, Lourwood DL. Low-molecular-weight hepa- bowel injury rins and their use in obstetrics and gynecology. Obstet Gynecol Surv. 1994;49:424–426. If the bowel has been prepped, and rectal 4. Magitbay PM, Nyholm JL, Hernandez JL, Podratz KC. enterotomy occurs during dissection, clo- Ovarian remnant syndrome. Am J Obstet Gynecol. sure and drainage are the only necessary 2005;193:2062–2066.

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