THE DILEMMAS OF THE LAPARASCOPIC SURGICAL SOLUTION

OF THE PELVIS FROZEN AT INFERTILITY – SURGERY WITHOUT

BOUNDARIES

Bojan Mrđanov

The General hospital in Subotica, Department of Gynecology and Obstetrics

PELVIS FROZEN

LAVH

TLVHTL

SHIVF

ICSI

AIH

EMBO

LISATIO

AID

AND TREAT

THERMA CHOICE

GnRH

PCT

TVT

TERMOABLATE EAS

HRTTVS

SIS

HY

S

AUB

PUL

OCHRA

GOLD

STANDARD CPP

OSA/LS

NICH

AMEA ACPO CEP

ESGE CSP STEP/W

LAPSIM

OSATS

TCU

IVS TOT

GO

LD S

TA

ND

AR

D

BMD

CAM

RCT

Pelvis frozen can be defined as a syndrom of complex adhesive changes of the pelvis space.

The frozen pelvis, with its own potential to damage the intestinal tract, the urinary tract, the nerves, the blood vessels, determines a surgical resolution of a problem of this kind, a difficult operation that

usually requires a multidisciplinary access .

Definition

Symptoms

pain

sterility

organic disfunctions

Causes

endometriosis

infectio

malignity

iatrogenics (radiation, a previous operation without the use of microsurgery principles)

The aim

The aim of the work is to estimate the possibility and success of laparoscopic surgery in solving the problem of the frozen pelvis at serious endometriosis at the consequences of a previous serious infection of the small pelvis.

Controversy

There is a controversy about if and how much the surgical intervention affects the ovarian reserve for an IVF procedure , however, there is no dilemma about the fact that the operation is the most common solution for the pain and the organic dysfunction.

Uber surgeon

The most ideal surgery of ’defrosting’ the small pelvis must include the following :

cessation of the pain

regeneration of the functional ability of the organ

not to lose the capability of fertility

If a gynecologist, a colorectal surgeon, a urologist, a vascular surgeon (?), a neurosurgeon (?) is

needed for the operation of deep ednometriosis we have to decide who is the best for the patient and who is the one with the most experience (skill?)

We have been interested in frozen pelvis cases at endometriosis and infections coupled with sterility, so post-operative results of adhesion distribution, the accessibility of Douglas’s pouch, the sticking of the ovaries to their pits, the passage of the fallopian (uterine) tube and some complications have been analysed.

26 cases of infertility have been analysed where the laparoscopy confirmed the pelvis frozen and after a few months the second look laparoscopy was done. Out of 26 cases, 17 were the consequence of serious endometriosis and 9 of previous infections ( 8 cases were the

consequence of a previous operation, 1 the consequence of chlamydial infection).

We were extremely interested in the passage of the fallopian tube after the first operation, which was checked out during the second

look operation.

Cases endometriosis infections

26 17 9

average age prim. infertility sec. infertilityendometriosis 34 16 1

infection 26 2 7

Transcience before therapy

proximal distal intranscient

endometriosis 15 2 2

infection 7 0 2

The second look operation had taken place after a six months’ therapy of continual contraception or GnRH analoguesst

proximal distal intranscient

endometriosis 16 11 1

infection 7 5 2

Distribution of adhesions

excellent good better no improvement

endometriosis

0 7 10 0

infection 0 4 5 0

Accessibility to the Douglas’s pouch

excellent good better bad

endometriosis

2 5 8 2

infection 0 4 5 0

Sticking of the ovaries to their pit

excellent good better no improvement

endometriosis

2 7 7 1

infection 0 4 5 0

Complications

re-laporoscopy injury transfusion

endometriosis 1 0 2

infection 0 1 (sigmoid colon )

1

The approach to the operative treatment of pelvis frozen requires :

sample analysismedicolleguial aspectmaking plans for solving individual anatomic

problemsforesight of possible iatrogenic damagesforesight of the need of a multidisciplinary teamaccepting the operation by an experienced and

skilled surgeon

Robotic

Conclusion

The mere idea of freedom of my thinking about the frozen pelvis is based on the knowledge of the cause and on the strictly determined approach to work and the modus of thinking which has roots not in freedom of will but in the freedom of necessity and skills. The sum of the developmental parts of the minimally invasive surgery lies in the timeless essence of classical surgery but observing the development of new surgical skills in full vibrancy of progress I strongly feel that this is just the breeze of a future time.

It is wrong to observe things under the aspect of eternity ( sub speciae

aeternitatis ) but they have to be seen as a last reality and together with

that our laments about some controversies will get some

credibility. Fugue (originating from the word fugere-to run, escape) from

necessary changes about the understanding of the last reality must

not belong to a surgeon.

Conclusion

Thank You