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 ligament between the divided round ligaments. Bodell Scott Copyright © SurgicalFor personal strategies use only to untangle a frozen pelvis IN THIS ARTICLE ❙ What to do Few surgeries 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 structures are distorted by extensive • Flexibility to change course when a ❙ Freeing the bladder 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 uterus 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, endometriosis, and ad- F infection, surgery, 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 endometrium and cervix 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 hysterectomy 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 ovaries. Re- tive trauma to these structures can lead moval of a retained left ovary 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 www.obgmanagement.com March 2007 • OBG MANAGEMENT 63 SURGICAL TECHNIQUES CONTINUED 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 laparoscopy 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 bleeding.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