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
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.
Identify landmarks
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.
