The common causes of extensive pelvic disease leading to frozen pelvis:

Infection. Adhesions and fibrosis secondary to infectious processes such as salpingitis, tubo-ovarian abscess, infected pelvic hematoma, and ruptured appendix can create severe pelvic adhesions. Abdominal Kochs can cause extensive Pelvic adhesions.

Surgery. The type of surgery a patient has undergone may provide important clues to potential problems. Laparotomy myomectomies and surgery for endometriosis can also cause gross adhesions. Residual ovaries and remnant ovaries after abdominal hysterectomy may require extensive dissection of the ureter and bowel.

Benign and malignant growths. Severe endometriosis 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.

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.

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 .When evaluating a patient, it is important to determine which of above etiological conditions exist. The physical examination also can be revealing. The type of laparotomy scars and drain sites will give a clue to the difficulty of the previous surgery. 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 ascertain 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.

Preoperative transvaginal sonography will be of immense value2. Magnetic resonance imaging may be worthwhile in some cases. It is particularly important to learn preoperatively whether there is hydronephrosis and involvement of the ureters.

Other diagnostic steps, such as cystoscopy and sigmoidoscopy, can be performed at the time of diagnostic laparoscopy or postponed until the actual surgery.

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 anticipation of possible enterolysis or intestinal tract surgery, all patients should undergo preoperative bowel preparation.
Plan for an introperative ureteral catheterization if gross pelvic side wall pathologies like severe endometriosis is diagnosed. The use of catheters helps the surgeon to identify the ureters intraoperatively and may therefore prevent their injury.

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. The prophylactic use of antibiotics and low-molecular-weight heparin is recommended3,4,5.

The most important step of the surgery is the abdominal entry. We create pneumoperitonum with a Veress needle at the Palmers point. The primary trocar entry is with a Ternamian endotip (Fig:1, Fig:2)at the umbilicus , Palmer’s point or 5 cm above the pelvic mass.

Ternamian endotip for primary trocar entry in to peritoneal cavity	sheath visualized through endotip during primary trocar entry

After entering the abdomen, identify pelvic structures and their location in relation to one another. Omental adhesions to parietal peritoneum are very common. Omental adhesions to parietal peritoneum are released with scissors, unipolar hook electrode or harmonic scalpel. A combination of blunt and sharp dissection is necessary in dense adhesions to visualize the
presence of intestine behind the omental adhesions

Bowel adhesiolysis is difficult if there is no space between the peritoneum and bowel(Fig:3). Dissection is done with hook electrode , scissors or harmonic scalpel in this situation. A combination of sharp and blunt dissection can make a space between the bowel and abdominal wall. Cutting close to peritoneum is safer (Fig:4).

After omental or intestinal adhesions have been separated, move the small and large intestines from the pelvis. Uterine manipulation with a suitable manipulator will allow the surgeon to identify the pelvic structures more clearly. We use a Clermont Ferrand uterine manipulator (Karl Storz)for hysterectomies. 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 in frozen pelvis.

Once the pelvic structures have identified, 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 coagulation and division 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. Several entry sites are possible. In the frozen pelvis, the round ligament is the ideal location. Identify and divide this ligament as it enters the internal ring, and incise the peritoneum cephalad along the course of the IP ligaments

In severe endometriosis, the adnexa are released from the pelvic side wall with blunt and sharp dissection. Dissection starts from a normal area of pelvis and adnexal is released from the pelvic side wall by sharp and blunt dissection. The ureter is identified on both sides before coagulating the IP ligament. This technique is possible in a good number of cases.

Never assume the position of the ureter without confirming it; a major deviation of its course can occur secondary to pathologic processes in the pelvis. The ureter can be identified by direct visualization, peristalsis, and palpation with a probe. Near the level of the pelvic brim on the left side of the body, the ureter will be closer to the IP ligament than it is on the right side, due to the location of the sigmoid colon and its mesentery on the left side, which elevate the ureter in the ventral direction.

ureteric catheterization with illuminated catheter	Illuminated catheter visible at the pelvic brim	Left ureter after separation of the adherent adnexa

Rarely an illuminated ureteric catheter is placed if ureters cannot be clearly identified. Ureteric cathetrisation can be done with an operating hysteroscope with little training(Fig: 5). The illuminated ureteric catheter can be visualized laparoscopically by reducing the laparoscopic light (Fig: 6). It also make the ureters rigid for palpation and dissection (Fig:7).

A history of surgery in the area of the bladder, such as cesarean section or bladder advancement with uterine suspension, may leave the bladder adherent to or hard to separate from the cervix and vagina. Normally, the vesicouterine peritoneum is flexible, mobile, and easy to free from the cervix and vagina. A history of disease processes such as endometriosis, infection, or tumors makes this dissection difficult, with a real risk of inadvertent cystotomy.

One technique to make this dissection easier and safer is to enter the retroperitoneum laterally near the round ligament. In this location, the bladder may not have been involved in the prior dissection, and the tissue may be more areolar and less dense than it is in the midline. Bladder is then separated from the cervix by a hook electrode or harmonic scalpel, remaining close to cervix. Fornix bulger of uterine manipulator can help in deciding the limit of bladder dissection. Very rarely filling the bladder with 200 cc of saline can help in identifying the bladder limit (Fig: 8,9).

Bladder is filled with 200 cc of saline to visualize the bladder limits	After bladder separation

Once the bladder separation is done , uterine vessels are identified at the isthmus and skeletonised. The vessels are coagulated with bipolar forceps and divided. Since the ureters is already identified, this step of laparoscopic hysterectomy is similar to any other hysterectomy.

In pelvis, the posterior cul-de-sac is bounded laterally by the uterosacral ligaments, posteriorly by the rectum and sacrum, and caudally by the vagina—but these relationships are usually lost in the frozen pelvis. Extensive inflammatory disease, tumors of the tubes and ovaries, extensive pelvic endometriosis, and prior infection due to a ruptured appendix can obscure the normal confines of the cul-de-sac. Freeing the peritoneal attachments both anteriorly and posteriorly, as well as at the sides of the pelvis, allow elevation of the uterus with the manipulator . Then the ureter, uterine vasculature, and supporting ligaments can be identified. Dissection becomes simpler after this point.

However, when the rectum is densely adherent, as they often are in the frozen pelvis, dissection can become difficult, with a real danger of rectal perforation. A basic principle in any hysterectomy is to remain close to the uterus, staying near the posterior surface of the uterus and cervix using both blunt and sharp dissection. This eventually makes it possible to find a reasonable plane to enter the rectovaginal space at the superior portion of the cul-de-sac between the uterosacral ligaments. The tissue below this level is not usually involved in the frozen pelvis and will give way readily once the uterosacral ligaments are divided. It is unnecessary to operate beyond this level to any great extent because the surgery already extends distal to the cervicovaginal junction.

In some circumstances, it may be necessary to open the vagina anteriorly to define the relationship between the posterior cervix and adherent bowel(fig 10). The hysterectomy is completed in a retrograde fashion. The adherent rectum is then separated from the uterus by sharp dissection in small steps (Fig:11).

Anterior vagina is incised and posterior vagina still attached to uterus	dividing the rectal adhesions to uterus after separating the cervix from the vagina

Vagina is now closed laparoscopically after removing the specimen vaginally. The vaginal angle sutures incorporates the uterosacral and cardinal ligaments for vault support (Fig.12) Peritoneal cavity is lavaged with saline and complete hemostasis is ensured. A drain is kept in the pelvis overnight.

Suturing the vaginal vault after hysterectomy

If rectal injury is suspected, insufflate the submersed rectosigmoid with air (Fig 13). Bubbles signal a breach in the integrity of the bowel wall. If the bowel has been prepped, and rectal enterotomy occurs during dissection, closure and drainage are the only necessary steps.

Rectum inflated with air to look for injury

Cystoscopy is performed to look for any bladder injury and see the urine reflux from both ureteric orifices.

We describe our experience in performing laparoscopic hysterectomy in frozen pelvis due to severe endometriosis or pelvic adhesions. There were 16 cases and all had history of previous surgery for endometriosis. 4 patients had two laparotomies, 8 had one Laparotomy, 1 had three laparoscopic surgeries, 4 had two laparoscopic surgeries, 5 had one laparoscopic surgery. It includes 4 cases where a previous laparotomy had failed to complete hysterectomy. All had frozen pelvis and endometriosis with or without adenomyosis. Laparoscopic adhesiolysis with total laparoscopic hysterectomy with bilateral/ unilateral salpingo-oophorectomy was done for all. One patient the biopsy report was well differentiated adenocarcinoma of the tubal stump. Average duration of surgery was 2 hours 30 minutes. Blood loss was less than 500 ml. No blood transfusion was given for any patient. There was no bowel or bladder injury in this series. Postoperative hospital stay was 2-3 days. 3 patients had postoperative fever which was treated with antibiotics.

Hysterectomy in frozen pelvis is a difficult surgical procedure whether done by open or laparoscopic route. A good preoperative evaluation and planning helps the surgeon to prepare for a difficult hysterectomy and organize intraoperative urological or gastrointestinal surgical consultation. Surgical technique has to be modified for a particular case and surgeon should be prepared to change the course of surgery. It is possible and safe to perform total laparoscopic hysterectomy in cases of frozen pelvis by experienced surgeons.

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