Endometriosis Foundation of America
Endometriosis 2013 / Frozen Pelvis & Stage 4 Endometriosis
Ted Lee, MD
Hi, I was given the topic of frozen pelvis and stage-4 endometriosis but I was not given a direction as to should I talk about the hysterectomy aspect of it versus the excision of it. So I went with the hormonal radical...aspect of it. My videos are very straightforward; it is relatively unedited for the most part.
In here you can see that this patient has a frozen pelvis obliteration of the cul-de-sac. As I have told many of the people who I teach, my residents and fellows is when you...difficult pathologies you always do the easy things first. I am not even going to deal with the whole operation of the cul-de-sac, I just start by hysterectomy. I pick my...ligament as if I pull it more, then obliteration of the cul-de-sac. The key to a frozen pelvis is to do the easy thing first and to find all your landmarks and restore your landmarks and that is why you need to do it with a hysterectomy for the pelvis.
At this portion of the procedure it is not much different from any hysterectomy. When you do easy things first what does that do for you? It boosts your morale, it boosts your confidence. For me it does. When everything is going well, everything is going the way it is supposed to go you are happy.
On the other hand you want to attack that...cul-de-sac first, you are going to be very frustrated. It will be bloody. It is kind of ugly. It is not a good thing. Here we are doing a bladder flap, this is now much different than any bladder flap that you would do. The key is to elevate the peritoneum, elevate the bladder when you do your bladder flap. This is pretty much all my videos - as little as possible just to give you the feel of being there with me. At this point you have not seen any editing at all. We just do the bladder flap. The next thing I am going to do is obviously the bowel on the left side. It is totally adherent. We will have to mobilize the bowel, push it up a little bit. The sigmoid colon is right here. The bowel is adhering to the adnexa...ability to see the ovary. The ovary is completely covered by the bowel.
We are going to get these congenital sigmoid adhesions off. This should be done very, very easily. This patient has both adenomyosis and bilateral endometrioma. She is older and no longer childbearing so we are doing a hysterectomy. We opened up the peritoneal or the pelvic brim. At this point, what I was going to do is find the uterine's origin since I have no access to the...branch of the uterine. This patient is obese so you can see a lot of adipose tissues but ultimately the first...structure I feel medial to the external iliac vessels is the upper umbilical ligaments right here because I feel that by palpation. We got rid of this piece of fat so I can get a better exposure. Once I have done that I am going to hand the...ligament to my assistant and the assistant is going to pull up towards the interior abdominal wall. Bring the structure of interest towards the surface. The structure of interest is the uterine artery from its origin. So, instead of digging deeper, bring the structure towards the surface. That is really the key to this approach.
Here is the umbilical ligament. My assistant is pulling the umbilical ligament interiorly towards the interior abdominal wall. This piece of fat, obviously, is in the way. Eventually I am going have my assistant retract that piece of fat out of my way. I switch hands and I will grab that umbilical ligament myself. My assistant is going to retract this piece of fat away from me and I will...towards the surface again. You will see soon that the uterine artery is right here. You can see that right here the beginning of the uterine artery. You can see that sort of curvy structure. That is very, very unique; the uterine artery has that very unique dimension to it. You see the uterine artery. Many times the patient has actually two separate branches of uterine, I think you might experience up to 33 percent of the cases patients might have two branches of the uterine. You can see here underneath the accessory uterine vessels right here. So a lot of times if you just ligate one you may not secure the blood vessels. They might actually kill the blood supply to the uterus. Here again we might have not done much editing. That is the uterine right there. I am going to go ahead...and if you seal the uterine right off the internal iliac and you are pulling cephalad anteriorly and towards laterally, here I can see the ureter. But it is completely safe when you do that. We will see both branches of the uterine. I have not even attacked the ligature in the cul-de-sac. It is still there.
The next thing I am going to do is to identify the IP. I do not even know where the ovary is at this point because it is all stuck behind the uterus. I'm looking, I'm feeling for the weakness, feeling where I can attack. A lot of bladder resection session that I perform is actually a form of interrogation, I am interrogating the tissues. The tissues give me information that I need to proceed further. If you are being the interrogator you can just over interrogate the witness and the witness will die and you will not get information. Here I am getting the bladder resection is interpreting the weakness and saying, "Ah, here is where I need to go". Here is a window between the IP and the ureter should be somewhere below the window. I am going to grab the IP here with what we call the earmuff, it is very similar to a Babcock. I told my fellows to clear the window there and we are going to lift the IP with my earmuff instrument. This instrument I have been using this since I was a fellow with Tom Lyons. I want to give him a lot credit for training me.
Here is the IP and the ureter is down below, you can see right there. We can just take the IP ligament right there. Again, I have not done a lesion anything with the frozen pelvis or with obliteration of the cul-de-sac. Obviously in a patient who you want to conserve the uterus and ovaries and so on, the surgery will be different than this because frequently you really have no choice but to attack the pathology directly and frequently...tends to be very bloody and not pretty. We take the IP here. If I do it on both sides the uterus now becomes bluish in appearance. If I cut off all the blood supply I then attack the bluish in the cul-de-sac. The rectum is complete, pass through to the uterus. You have bilateral hydrosalpinges on this patient. Some of these adhesions are filmier but as we go down deeper, right behind the cervix, the adhesions become much, much thicker...first time we see a glimpse of the ovary on the right side. You can see a glimpse of ovary on the left side over there. I guess you know once you cut the blood supply it becomes easier but at the same time the game is not over yet. Because you still have all this stuff, very fibrotic adhesions that you are dealing with and now get into the endometrioma here. A lot of this becomes tedious...if the endometriosis involving the bowel, so here is endometriosis behind the cervix here. Here is the...here palpating. Here is the colorectal surgeon's parietal space, his rectovaginal space so I am just going to connect the dots. This is a good plane and this is a good plane and it is connecting a lot and dropping the rectum completely. Here is the fat. The fat is your friend when you see fat in the right tissue plane. So, one side in the right tissue plane I am going to stick it in the right tissue plane and complete my dissections. Complete the dropped rectum completely.
So, even if the bowel is involved you need to drop the rectum. If you need to do an enucleation of the endometriosis of the rectum you need to repair it. The bowel needs to be completely dropped off its attachments to the vagina. The cul-de-sac is completely free and is fine but we have a problem here on the left side. The ureter is still somewhat attached to the ovary on the left side here. We have to perform the ureterolysis. But the good news is that I already ligated the uterine from its origin on the left side. When I begin to do the ureterolysis I do not have to worry about the...crossing over the ureter because if I had not ligated the uterine vessels from their origin I would get a lot of bleeding doing that portion of ureterolysis.
The uterus is right here, the ovary is right here, these are the fibrosis. Normally the uterine is going to cross somewhere around here but I like it way up here already I do not have to worry so much. The bleeding should be very, very minimal. If I get the uterine there should not be bleeding it could be all black bleeding because the uterine vessel has already been secured. Here is the ureter. And this is probably like part of either the uterosacral or actually the inferior hypogastric plexus medial to the ureter, right here and completely free on this adnexa right there. Here is a nice tissue plane. Again, you sort of feel, touch, see how the tissue reacts to you and you move. A lot of times the surgery in difficult situations is a lot about touching and feeling and pulling just to get that information you need. Once you get the information you need you proceed.
Now the ureter is freed up and part of my circumference right here. The...is right there. Once you free that up then when you finish...and this is where the bowel adhesion use to be way up near the pelvic brim. And that is the hysterectomy in the frozen pelvis.
That is pretty much my talk.