and Jyothi G Seshadri2
Frozen pelvis is a condition where dense adhesions due to any condition can result in pelvic structures becoming densely adhered and fixed to each other and to the pelvic walls. This could be due to endometriosis, pelvic inflammation (tuberculosis or otherwise), multiple previous surgeries, etc. [1, 2].
Note: The examples shown in Figs. 3.27a–d and 3.28a–f are not that of frozen pelvis. The bowels and the pelvic structures are not plastered to each other or to the abdominopelvic walls. There is no significant adhesion formation; the problem in these situations is how to locate the ureter given the fact that there are no surgical landmarks.
Open the abdomen through a vertical incision or preferably first insert a laparoscope by the open method. There could be dense adhesions right under the umbilicus, and open method would be safer though not fool proof. Examine the peritoneal cavity and decide if the case can be accomplished laparoscopically or will laparotomy be necessary. If the abdomen has been opened by a transverse incision inadvertently, decide if the surgery can be accomplished by converting the incision to a Maylard incision. Otherwise, close the abdomen and explain to patient and relatives that the in situ findings were far more complicated than what was determined by clinical evaluation and imaging. Plan a laparotomy through a vertical incision at a later date. This option is ideal if the disease is not an emergency condition. Remember surgery is a diagnostic tool and one should not be embarrassed to have opened the abdomen just to find out what the disease is. Explain this confidently and patients will understand.
The other option is to convert the incision into an inverted T incision. This is the least cosmetically preferred incision and is associated with higher postoperative morbidity and a higher risk of future incisional hernia (as compared to vertical incision). Trying to operate in the upper abdomen through a transverse incision can lead to suboptimal surgery, and the chances of visceral injuries are high.
Use sharp dissection always. The dense adhesions would have plastered the bowels to each other and to the pelvic structures. The adherent bowels should not be separated by peeling or by blunt dissection with wet or dry gauze.
Try and locate the round ligament and take a stay suture on it. Cut it and open the retroperitoneal space. Locate the ureter and take it on a tape if required. This will lateralize the ureter and keep it away from the operating field.
If one cannot locate the round ligament, catch a fold of peritoneum in the lateral wall of pelvis with a forceps. Open it after confirming that there is no vessel or tubular structure underneath. Gently extend the opening millimeter by millimeter and locate the ureter.
If the patient has received previous radiation, let us say for carcinoma cervix, it will be difficult to reach the internal iliac artery. So remember that if one encounters profuse bleeding, it will be very difficult to do internal iliac artery ligation to control hemorrhage. Similarly, be cautious while separating the uterovesical fold. The chances of bladder injuries are high and so is the risk of developing vesicovaginal fistula.
Let us now study some photographs taken from a case where an in situ finding of frozen pelvis was found.
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