Frozen Pelvis Surgical Strategy in 10 Steps

STUDY OBJECTIVE: To describe a 10-step strategy to treat severe endometriosis with a frozen pelvis by laparoscopy. DESIGN: Educational video. SETTING: University Hospital of Strasbourg, France. INTERVENTIONS: The patient was a 33-year-old nulliparous woman suffering from endometriosis. Because of pain and a desire for pregnancy, she was scheduled for surgery. After setting the patient in gynecologic position, we used a uterine manipulator to facilitate exposure. We assessed the global situation and discovered a frozen pelvis. To treat the myoma, the surgeon should use traction and countertraction as much as possible. We started with the caecum and sigmoid detachment. Then we performed a bilateral ureterolysis. Once the ureters were identified, we could perform safely the adhesiolysis of the bowel from the uterus. The adnexas could be freed and suspended with a T-Lift device to facilitate exposure. After identifying the utero sacral ligament, we opened the para rectal fossa, leading to the opening of the recto vaginal space. The anatomy was then restored, and we could define the specific surgical strategies. CONCLUSION: Frozen pelvis is a situation where anatomy is distorted. The surgeon should find anatomic landmarks to restore anatomy and to establish specific strategies adapted to the patient.