{"paper_id":"09047c7d-894d-416f-af86-394a8c0fef5a","body_text":"CLINICAL PRACTICE\nTotal laparoscopic extirpation of a fixed uterus from benign\ngynecological disease\nM. Sami Walid & Richard L. Heaton\nReceived: 14 December 2009 / Accepted: 8 January 2010 / Published online: 4 February 2010\n# Springer-V erlag 2010\nAbstract Frequently, a fixed pelvis is encountered that is\ncaused by a benign disease, either severe endometriosis or\nsevere adhesions with or without fibroid uterus. We present\ntwo cases of nulligravida and multiparous women who had\nabsolute frozen pelvises with no motion whatsoever of their\npelvic structures on bimanual examination. Conventionally,\nthese patients would have been approached by open\nhysterectomy only. We do not consider a frozen pelvis\nfrom what appears to be a benign case a contraindication to\nthe laparoscopic approach.\nKeywords Fixed pelvis . Impacted uterus . Retroverted\nuterus . Obliterated cul-de-sac . Adhesions . Endometriosis .\nLaparoscopic hysterectomy\nIntroduction\nA fixed pelvis usually implies the possibility of malignancy\nspread along the broad ligaments and the parametrium to\nthe pelvic sidewall. However, more frequently, a fixed\npelvis is caused by a benign disease, either severe\nendometriosis or severe adhesions with the bilateral tubo-\novarian complexes adherent to the pelvic sidewalls or from\na large fibroid uterus associated with scar tissue or\nendometriosis [ 1, 2].\nThe following two cases are of women who had absolute\nfrozen pelvises with no motion whatsoever of their pelvic\nstructures on bimanual examination. Conventionally, these\npatients have been approached by open hysterectomy and\nconsidered unfit for laparoscopic treatment [ 3]. This has not\nbeen our experience. We do not consider the frozen pelvis\nin what appears to be a benign case a contraindication to\nthe laparoscopic approach.\nCase 1\nA 42-year-old woman, gravida 0, was admitted for the\ndefinitive surgical treatment of her chronic cyclic pelvic\npain, dyspareunia, menorrhagia, and a large fibroid uterus.\nThe patient had a fixed pelvis on pelvic exam. On\nlaparoscopy, she was found to have dense adhesions with\nan obliterated posterior cul-de-sac with the uterus fixed in\nplace and immobile. Total laparoscopic hysterectomy,\nbilateral salpingo-oophorectomy, ureterolysis, and enterolysis\nwere performed. The uterus weighed 208 g. Operative\ntime was 131 min, and estimated blood loss was 150 cm\n3.\nFigures 1, 2,a n d 3 are from this case.\nCase 2\nA 39-year-old woman, gravida 3 para 3, complained of meno-\nmetrorrhagia, chronic pelvic pain, and deep dyspareunia,\nworse on the left. On pelvic exam, her uterus was retroverted,\nand the right ovary was felt in the posterior cul-de-sac, which\nwas suggestive of adhesions. Her left ovary was enlarged,\nfilling the left half of the pelvic cavity. The uterus and adnexa\nfelt fixed in place. Ultrasound revealed what appeared to be a\nhemorrhagic cyst in the right ovary and a large cystic mass in\nthe left ovary that was single-locular and thin-walled,\nM. S. Walid\nMedical Center of Central Georgia,\n840 Pine Street, Suite 880,\nMacon, GA 31201, USA\ne-mail: mswalid@yahoo.com\nR. L. Heaton ( *)\nHeart of Georgia Women ’s Center,\n209 Green Street,\nWarner Robins, GA 31099, USA\ne-mail: riclheaton@yahoo.com\nGynecol Surg (2011) 8:157 –159\nDOI 10.1007/s10397-010-0558-3\n\nmeasuring 7.8 cm in largest diameter. Her CA-125 was 47\n(minimally elevated). She had a score of nine on Pelvic Pain\nand Urgency/Frequency questionnaire. Her findings were\nsuggestive of endometriosis. There was no adenopathy on\ncomputed tomography scan but some dilatation of the left\nureter, suggestive of partial obstruction and, most likely,\nsome retroperitoneal fibrosis on the left. The patients had a\nhistory of three C-sections. She was counseled about her\noptions and decided with the physician to proceed with\nlaparoscopy with possible conversion to open surgery. The\npatient was found to have bilateral endometriomas, left larger\nthan right; tubo-ovarian complexes scarred into the pelvic\nsidewall on both sides; dense adhesions of the vesicouterine\nreflection (from prior C-sections); and severe enteric adhe-\nsions. The patient underwent total laparoscopic hysterectomy,\nbilateral salpingo-oophorectomy, bilateral ureterolysis, and\nenterolysis. The operation lasted 147 min. Blood loss was\nestimated at 100 cm\n3. On cystoscopy and hydrodistension,\nthe patient was found to have glomerulations throughout the\nbladder, consistent with interstitial cystitis. The removed\nmaterial weighed 231 g. Operative time was 147 min (2 h\nand 27 min), and estimated blood loss was 100 cm 3.\nFigures 4, 5,a n d 6 are from this case.\nDiscussion\nWhen dealing with cases of frozen pelvis, the surgeon\nshould always follow the surgical principles of exposure of\nnormal organs that should not be injured. You take what the\nindividual case easily offers you in way of adhesiolysis in\norder to restore normal anatomy. You begin by deflecting\nthe sigmoid colon, medially separating its attachment to\nthe left pelvic sidewall and exposing the bifurcation of the\nexternal iliac artery and the internal iliac artery (the\nhypogastric artery). Normally, the left ureter will be found\ncoursing over or close to this junction which allows one to\nbegin the retroperitoneal pelvic dissection that allows these\nFig. 4 Impacted fixed uterus (case 2)\nFig. 3 Ureterolysis completed (case 1)\nFig. 2 Ureterolysis in process (case 1)\nFig. 1 Adhesions of the sigmoid to the left ovary (case 1)\n158 Gynecol Surg (2011) 8:157 –159\n\ncases to be safely done. Initially, the dissection of the ureter\nis begun retroperitoneally. Once there is a safe margin\nbetween the infundibulopelvic (IP) ligament and the ureter,\nthe IP is coagulated with bipolar or harmonic energy or tied\nup giving further anterior exposure and enabling deeper\nadvancement of the ureterolysis procedure. Normally, at\nthis point, the round ligament can also be coagulated (to\ncontrol bleeding from Samson's artery) and divided, giving\nfurther exposure to the course of the ureter and allowing the\nuterus and adherent bowel to be displaced medially. At this\npoint, the peritoneum of the anterior broad ligament can be\ntaken down past the pelvic midline on the left side exposing\nthe cervix and allowing further medial displacement of the\nadherent uterus and sigmoid. This allows optimal visuali-\nzation of the pelvis on the left so the ureter can be easily\nfollowed to where it disappears into the cardinal ligament\nweb. The uterine artery will reliably be found coming over\nthe ureter at this level and, depending on the anatomy, can\nbe clipped, tied, or bipolar-coagulated lateral to the ureter\ncontrolling the third vascular pedicle coming to the uterus\nfrom the left side. At this point, the dissection is taken to\nthe right side, and exactly the same procedure is followed.\nThis results in near-complete devascularization of the uterus\nwith exception of possible input from the descending\ncervical branch of the uterine artery if it has a collateral\nattachment to the azygos vaginal artery. At this point, if\nthere are significant vesicouterine adhesions anteriorly from\nprior C-sections, infection, or endometriosis, these are taken\ndown to further free the adherent adnexal-uterine-sigmoid\nmass. This is usually done easily by coming in under the\nscar bands laterally turning the active blade of the harmonic\nace down into the cervix and pulling briskly through the\nedge of the scar band. This process can be serially repeated\nuntil the scar bands are completely separated from the\ncervix. The normal areolar plane between the bladder and\nthe lower uterine segment can now be entered and the\nbladder taken down off of the lower uterine segment,\ncervix, and upper vagina. The dissection of the posterior\ncul-de-sac is then addressed. Medial retroperitoneal dissec-\ntion is done utilizing the prior ureterolysis incisions. This\nallows visualization of the retroperitoneal course of the\nsigmoid allowing safer dissection of the sigmoid from\nthe adnexal structures and lat eral uterus. The final step of\nthe dissection is then ready to be done. With the uterus\ndevascularized, the serosal plane of the uterus can be\ndissected deliberately erring on the side of myometrial entry.\nSince the uterus is devascularized and bleeding is minimal,\nthe easily recognized myometrium allows continual correc-\ntion to the serosal plane and safe dissection of the sigmoid\nfrom the back of the uterus and reopening the posterior cul-\nde-sac. The patient can now have standard completion of the\ntotal laparoscopic hysterectomy.\nThese cases usually take at least 2 –3 h for an experienced\nlaparoscopist. They can be time-consuming but are usually\nnot difficult to do as long as the principles set above are\nfollowed.\nConflict of interest There is no actual or potential conflict of\ninterest in relation to this article.\nReferences\n1. Kataoka ML, Togashi K, Yamaoka T, Koyama T, Ueda H,\nKobayashi H, Rahman M, Higuchi T, Fujii S (2005 Mar) Posterior\ncul-de-sac obliteration associated with endometriosis: MR imaging\nevaluation. Radiology 234(3):815 –823\n2. Amin-Hanjani S, Nyirjesy P (1994) Incarcerated fibroid uterus: a\nrare cause of acute abdominal pain in a nonpregnant patient. J\nGynecol Surg 10(2):97 –98\n3. Agency for Health Care Policy and Research (1995) Treatment of\ncommon non-cancerous uterine conditions: issues for research.\nconference summary. AHCPR Publication No. 95-0067, July\n1995. Agency for Health Care Policy and Research, Rockville.\nhttp://www.ahrq.gov/research/uterine.htm\nFig. 6 The iliac bifurcation (case 2)\nFig. 5 Exposing the bifurcation of the iliac artery (case 2)\nGynecol Surg (2011) 8:157 –159 159","source_license":"CC0","license_restricted":false}