THE DILEMMAS OF THE LAPARASCOPIC SURGICAL SOLUTION OF THE PELVIS FROZEN

AT INFERTILITY SURGERY WITHOUT BOUNDARIES

Authors:
Luka M.Aneli,Bojan Mranov,Vera Kovaevi,Andor Goli
The General hospital in Subotica, Department of Gynecology and Obstetrics

Abstract

Pelvis frozen can be defined as a syndrom of complex adhesive changes of the

pelvis space. The frozen pelvis, with its own potential to damage the intestinal tract,
the urinary tract, the nerves, the blood vessels, determines a surgical resolution of a
problem of this kind, a difficult operation that usually requires a multidisciplinary
access (1). The symptoms include pain, sterility and organic disfunctions. The
causes are in the endometriosis, infectio, malignity, iatrogenics (radiation, a
previous operation without the use of microsurgery principles)
The aim of the work is to estimate the possibility and success of laparoscopic
surgery in solving the problem of the frozen pelvis at serious endometriosis at the
consequences of a previous serious infection of the small pelvis. There is a
controversy about if and how much the surgical intervention affects the ovarian
reserve for an IVF procedure (2), however, there is no dilemma about the fact that
the operation is the most common solution for the pain and the organic dysfunction.
The most ideal surgery of defrosting the small pelvis must include the following:
cessation of the pain, regeneration of the functional ability of the organ, and not to
lose the capability of fertility ( 5) If a gynecologist, a colorectal surgeon, a urologist,
a vascular surgeon (?), a neurosurgeon (?) is needed for the operation of deep
ednometriosis we have to decide who is the best for the patient and who is the one
with the most experience (skill?) 3
We have been interested in frozen pelvis cases at endometriosis and infections
coupled with sterility, so post-operative results of adhesion distribution, the
accessibility of Douglass pouch, the sticking of the ovaries to their pits, the passage
of the fallopian (uterine) tube and some complications have been analysed.
26 cases of infertility have been analysed where the laparoscopy confirmed the
pelvis frozen and after a few months the second look laparoscopy was done. Out of
26 cases, 17 were the consequence of serious endometriosis and 9 of previous
infections ( 8 cases were the consequence of a previous operation, 1 the
consequence of chlamydial infection). We were extremely interested in the passage

of the fallopian tube after the first operation, which was checked out during the
second look operation.

Out of 17 cases of endometriosis, at 15 the proximal transcience was more or less

preserved, distal at 2 cases and intranscient at 2 cases. The second look operation
had taken place after a six months therapy of continual contraception or GnRH
analogues and at 16 cases we had proximal transcience and at 11 cases a distal
one. The establishment of proximal transcience in 1 case can be attributed to an
earlier technical problem or the remission of pressure from a joint adenomyosis.
Out of 9 cases the consequence of infection at 7 were the presence of proximal
transcience and distal transcience was not confirmed at either case and the
proximal occlusion was present at 2 cases. During the second operation (after 4
months up to a year without any defined therapy) we find distal transcience at 5
cases.
During the second operation the distribution of adhesions was analysed and the
results were not ideal but could be described as better or even good at a small
number of cases.
The accessibility to the Douglass pouch at the cases of endometriosis was still bad
at 2 cases, better at 8 cases, good at 7 cases and great at 2 cases. When speaking
about the consequences of infections, at 5 cases the results were better, and at 4
cases were good.
We also analysed the sticking of the ovaries to their pit. With endometriosis, at one
case there was no improvement, at 7 cases the results were better, at 7 cases they
were good (elevated ovaries) and at 2 cases the results were excellent (elevated
ovaries).With infection, the results were better, and at 4 cases were good.
We also analysed the complications and in one case of serious endometriosis a relaporoscopy had to be done after 16 hours because of severe bleeding and at two
cases a transfusion was needed. When speaking about the cases that are the
consequence of infections, in one second look laparoscopy it came to the injury of
the sigmoid colon that was taken care of with a stitch 4-0 PDS without any postoperative problems and transfusion was needed in one case.
The approach to the operative treatment of pelvis frozen requires :
1.
2.
3.
4.
5.
6.

sample analysis
medicolleguial aspect
making plans for solving individual anatomic problems
foresight of possible iatrogenic damages
foresight of the need of a multidisciplinary team
accepting the operation by an experienced and skilled surgeon (4)

The mere idea of freedom of my thinking about the frozen pelvis is based on the
knowledge of the cause and on the strictly determined approach to work and the
modus of thinking which has roots not in freedom of will but in the freedom of
necessity and skills. The sum of the developmental parts of the minimally invasive
surgery lies in the timeless essence of classical surgery but observing the
development of new surgical skills in full vibrancy of progress I strongly feel that
this is just the breeze of a future time.
It is wrong to observe things under the aspect of eternity ( sub speciae
aeternitatis ) but they have to be seen as a last reality and together with that our
laments about some controversies will get some credibility. Fugue (originating from
the word fugere-to run, escape) from necessary changes about the understanding of
the last reality must not belong to a surgeon.
1. Mohr C,Nezhat F et al. JSLS 2005,9(1):16-24
Fertility considerationin laparoscopic treatment of infiltrative bowel
endometriosis
2. Barnhart and al.Fertil Steril 2002
Surgery for endometriosis and IVF success
3. Redwine D:J.Reprod.Medicine 1992 :37 (8)
Laparoscopien bloc resection for treatmant of the obliterated cul-de-sacin
endometriosis
4. Nezhat C. AAGL 2010
History of the Frozen Pelvis and a Brief Overview of What it Involves
5. Koh C.H. AAGL 2010
Obliteration of the Cull-de-sac,colonic Involvement