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Surgical management of the frozen pelvis Dr Paul Indman, Dr Alan Lam, Dr Charles Koh, and Dr Kai
Yin See Tho Dr.
Paul Indman:
I’m Paul Indman and we’re at the AAGL meeting in Las Vegas, Nevada.
We’re talking about the management of the frozen pelvis laparoscopically,
which is a problem for all of us when we get in, and all we see is a mess. I
have with me Dr. Kai Yin See Toh from Singapore, Dr. Charles Koh from Milwaukee,
and Dr. Alan Lam from Australia. Let me ask
you first Dr. Lam; here we are, we’ve put the laparoscope in, and
unfortunately we don’t see the inside of the bowel, but we see bowel all
around and omentum adhesions, where do we start? Dr.
Alan Lam:
What we need to do is to assess whether the case can be done safely, and
whether the surgeon has the appropriate skills. Assuming that the surgeon has
the appropriate skills, we aim to restore the anatomy back to normal. In other
words free adhesions away so that we can see the extent of the pelvic problems.
And that’s where we start. Dr.
Paul Indman:
Ok, you look around and you say “I can do this”. Dr. Koh, it’s
still a mess, you say, “I think I can do it”, where do you go? You don’t
see any place you can put a port, what instrument do you use to start breaking
down adhesions? Dr.
Charles Koh:
Well, in the case of a woman with a lot of previous laparotomies, you
expect adhesions. You would often use an alternative port. I happen to use the
left upper quadrant and I go in with a 5 mm visiport, so I can see as I go in.
And once you are in, hopefully that being an area that doesn’t usually have
adhesions, you can assess the rest of the abdomen and from there you can put in
your second port and third port. So, if
necessary you may need to operate from upper positions, and do the adhesiolysis
until you can place the umbilical port and lower trocars. This is necessary in
extreme situations where the case is really difficult. The big
picture of the operation has to be always kept in mind. Are you there to do
adhesiolysis for symptoms, or are you there to do primary surgery; say in the
pelvis and the adhesiolysis is to allow you to get to where you are? If that’s
the case, adhesiolysis should be limited to what is necessary to get down
safely, so you don’t have to do adhesiolysis near the liver and so on. Dr.
Paul Indman:
Dr. See Tho, let’s say you are looking in, do you use the left upper
quadrant? Dr.
Kai
Yin See Tho:
I do. If I feel access from the middle port may be dangerous, I use the
left upper quadrant, the so-called Palmer’s Point. I will insert a 3mm scope, take a look inside, check the
severity of the adhesions and the nature of the pathology, and as Charles has
said, go back to the centre if possible. I think
basically in this instance, recognition of
the pathology is our number one priority before progressing to definitive
surgery. Dr.
Paul Indman:
Dr. Lam do you try to go retroperitoneal? Let’s say someone has an 8 cm
ovarian cyst, she’s had multiple laparotomies, and again it’s a mess.
She’s had endometriosis, you think it’s probably an endometrioma; how do try
to find this ovary in this mess of adhesions? Dr.
Alan Lam:
Freeing the adhesions is a relatively simple step. Getting inside with
the appropriate energy source, in order to see the full extent of the entrapped
ovary, is the picture you are painting here. It is not difficult. But
determining the next step and how to approach the blood supply to the ovary, and
how to prevent damage, or potential damages, that can occur in the process of
removing the damaged ovary, or the cyst in the ovary, require special skills. One needs to
see the ureter, which is an important landmark that can almost always be
dissected out and used as a landmark to follow the path down into the pelvis.
From there, one is able to safely mobilise the entrapped ovary from the pelvic
side wall; ligate the blood supply to it in the process if one was considering
removal of it, or freeing it well enough in order to determine if it can be
removed, the cyst, or if the whole ovary must be removed. Dr.
Paul Indman:
In this frozen pelvis what is your approach to finding the ureter? Dr.
Alan Lam:
If it is on the left hand side, which is the more difficult side, then
mobilising the sigmoid adhesions away from the left pelvic bridge, adequately
high enough so that you can see the blood supply and the left ureter. And in
this area almost always one can see the left ureter, and need to see it above
the pelvic rim, so that one can then work from the ureter to move away the
adhesions that often entrap the ovary onto the pelvic side wall. Dr.
Paul Indman:
Dr. Koh, do you start out finding the ureter as your first step, or do
you look for, do you try to lyse all the adhesions first? Dr.
Charles Koh:
It depends on circumstances. If the only aspect of the frozen pelvis is
adherence of the bowel to the uterus, and both uterosacral ligaments and
perirectal space are available and free, you can go directly to free the rectum.
But most of the time you will have sigmoid attached to the ovary, or in this
case, to the ovarian cyst. Any time the
sidewall is plastered with adhesions, or bowel, you have to bring down the
sigmoid to identify the ureter. It is the only way that you can then progress
towards the ovary. Elevate the ovary, with the peritoneum if you have to.
Dissect the ureter further down towards the uterosacral ligament, ureteric
tunnel, and then you know that what’s lateral is safe and what’s medial is
bowel, and then you begin to identify where the bowel is. And between the ureter
and bowel is usually all the deep endometriosis that needs to be resected
laterally, because centrally you’ve got more work to do. Dr.
Paul Indman:
Dr. See Tho, imagine the situation that we encounter frequently where you
have the sigmoid colon and the rectum plastered cohesively against the top of
the fundus. There’s no plane. You try and dissect it out and you have
endometriosis, totally gluing the sigmoid to the uterus. Do you call a general
surgeon or are there some tips you can give for the gynaecologist to safely free
these adhesions? Dr.
Kai
Yin See Tho:
Well I guess if it is really dense and you can’t see to navigate you
will probably have to call somebody. I think in the majority of cases, one can
free some of the adhesions; you usually will be able to find some sort of a
plane. I think in this circumstance, what’s most important is that you must
have the right instrument, and the proper equipment to slowly dissect the plane. Dr.
Paul Indman:
What do you think are the best instruments? Dr.
Kai
Yin See Tho:
I think good vision and magnification is most important.
Next, the positioning of the patient is important too.
Adequate Trendelenburg is essential.
Lastly, the energy source, be it the laser or scissors.
These are crucial to safe dissection.
And then you try and see if you can get the plane between the fundus and
the uterus and the intestines. And you work from where you can see.
It is always the top down kind of approach. Dr.
Paul Indman:
Do you think it’s safe to be using, let’s say electro-surgical
instruments on a bowel? Remember, here’s a specific situation; you have the
uterus and you have sigmoid, and the uterus is sitting here and the sigmoid is
just stuck to there. Is it ok to take a monopolar instrument and go through
there? Or would you put in perhaps one of the bipolar instruments between the
two. Dr.
Kai
Yin See Tho:
No. I wouldn’t do either actually. I will actually use a very fine scissors
and slowly find the plane and cut. Maybe you encounter a little bit more
bleeding, but I it’s nice to see fresh tissue and
that helps you to dissect. I will not use an energy source, though
there’s one energy source product, and Charles probably uses it quite a bit,
the KPT laser, which is a very precise energy source that cuts to a pre-set
depth. And you can use that for
much closer dissection. I think clearing the adhesions with fine scissors is
probably the safest. Dr.
Paul Indman: Dr.
Koh, do you use the KTP or CO2 Laser in that situation generally, or
are you going to use scissors?
Dr.
Charles Koh:
For me personally, I will use a KTP laser. Scissors
are also acceptable, but if you are dealing with a totally fused bowel with no
plane, the laser is the only thing that can sculpt, and it’s a unique style of
surgery. If you use an instrument that works by coapting, it will not be able to
tackle this fused bowel. With the KTP laser, we make linear micron deep cuts and
you can see the bowel drop as you make sequential incisions. Before you
tackle such an extensive thing you have to have a lot of experience doing more
minor bowel freeing. Then you have confidence of the lateral spread of energy
based on your speed, and the power of that energy you are using. Once you can do
that, then whatever tool you are using, and I use the laser, you can
sequentially bring this bowel down. But what is
also very important is what you do afterwards. I will tend to over sew the area
if I’m a bit concerned about it, as opposed to just hoping that I did a really
nice clean job. Dr.
Paul Indman:
We can talk for hours about this and I would encourage anyone who is
interested to come to the next AAGL meeting, where we will have three or four
days to discuss this. I would like to thank everybody for coming and talking to
me. Thank you. MIMIS, The Milwaukee Institute of Minimally Invasive Surgery at Columbia St. Mary's is the Midwest's first multi-specialty minimally invasive surgical center of excellence. Established in 1992 by a group of highly respected leaders in the field of minimally invasive surgery, the Institute grew out of a strong desire to provide the most innovative surgical care and treatment for patients. In addition to providing excellent patient care, physicians of the Milwaukee Institute of Minimally Invasive Surgery have published books and articles, reported their results in medical literature, and taught and lectured worldwide. [http://www.mimis.us/]
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