Surgical anatomy of the frozen pelvis

November 4, 2020
Bob Kronemyer

Freelance writer for Contemporary OB/GYN

“Operating on a frozen pelvis is probably the most difficult situation a gynecologist can face within his surgical activities,” said moderator Mario Malzoni, chief of the Endoscopica Malzoni Center for Advanced Pelvic Surgery at the National Center for Endometriosis, in Avellino, Italy.

Identifying clear anatomical landmarks and incorporating surgical principles for a safe approach when operating on a frozen pelvis in a complex scenario will be highlighted in a panel discussion at the American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress, which is being held Friday, Nov. 6 through Saturday, Nov. 14.

Register here.

“Operating on a frozen pelvis is probably the most difficult situation a gynecologist can face within his surgical activities,” said moderator Mario Malzoni, Chief of the Endoscopica Malzoni Center for Advanced Pelvic Surgery at the National Center for Endometriosis, in Avellino, Italy, which is a referral center for diagnosing and treating endometriosis and other complex benign and malignant gynecologic diseases.

Frozen pelvis refers to a condition in which pelvic organs are distorted and tethered to each other as a consequence of adhesive processes. “It is commonly seen with endometriosis,” Dr. Malzoni told Contemporary OB/GYN. “Other causes are tumors; infections, including pelvic inflammatory disease; postsurgical adhesions; and post-treatment, such as radiotherapy, which results in fibrotic changes.”

Dr. Malzoni said frozen pelvis can obscure normal anatomical landmarks and surgical planes, thus increasing the risk of intraoperative and postoperative complications. “Frozen pelvis is one of the most challenging situations a surgeon can face,” he said. “There are only a handful of surgeries that require the judgment, rigorous experience, and skill necessary to operate on a frozen pelvis.”

The panel discussion is entitled “The hidden doors and the emergency exits: how can surgical anatomy of the pelvis be your Ariadne’s thread in the distorted anatomy maze.”

“Of course, Ariadne’s thread is not a medical term,” Dr. Malzoni said. “It is an expression that refers to the legend of Ariadne, who was a Cretan princess in Greek mythology. Ariadne gave her lover a ball of red thread to help him solve a vexing problem by multiple means through an exhaustive application of logic to all available routes.”

Because the frozen pelvis is an extremely complex situation in which normal anatomy can be distorted, “the only key to a right approach is to ‘find the way’ by recognizing and opening proper pelvic spaces,” Dr. Malzoni said.

Surgical strategy is crucial and should be appropriately planned and executed to avoid unnecessary and potentially damaging procedures, he said.

“The concept of ‘pelvic surgeon’ is probably the key: a gynecologist with full competence in colorectal, urologic, vascular and neuropelveologic surgical procedures,” Dr. Malzoni said.

In all benign conditions, especially endometriosis, and in many cases of malignancies, functional organ damage can occur with a frozen pelvis. Bowel subocclusion/occlusion or urinary tract impairment requires specific surgical procedures, ranging from bowel nodulectomy (shaving or discoid resection) to segmental resection like ureterolysis/resection, anastomosis or reimplantation, and bladder resection.

“Treatment should be tailored and, when possible, aimed at restoring normal anatomical conditions, along with preservation of visceral innervation by nerve-sparing techniques,” Dr. Malzoni said.

Dr. Malzoni does not believe any of the information being presented will be a surprise to clinicians, but rather reinforce effective and safe approaches. “In this case, safety and efficacy go hand in hand,” he said. “The ability to recognize and preserve ureters and neural fibers are crucial. At the same time, you need competence to avoid vascular injuries, and solve them if they occur.”

The session will take place on Nov. 12 and will demonstrate the secrets for safe and radical anatomical dissections of the pelvis, with the goal of removing the whole disease with the least complications. There also will be numerous surgical videos and schematics of a variety of possible scenarios encountered in daily practice.

Check out this link for the schedule-at-a-glance, and register here.

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Dr. Malzoni reports no relevant financial disclosures.