Unravelling the frozen pelvis caused by severe pelvic endometriosis remains to be the most challenging and time-consuming process in gynecological laparoscopic surgeries. We try to develop a systematic approach way to make our surgery effective and safe by mostly blunt and sharp dissection with minimal electrical energy.

Design:

Upon reviewing the surgical videos and drawing from our expanding surgical experience and anatomical understanding, we have devised systematic strategies to address the complexities of the frozen pelvis.

Setting: Single hospital, single leading surgeon with a surgical team

Patients or Participants: All patients with severe pelvic endometriosis causing frozen pelvis

Interventions:

Conventional straight stick laparoscopic instruments are utilized, maintaining the haptic feedback crucial for effective blunt dissection. To address a frozen pelvis, a retroperitoneal approach is essential. Developing retroperitoneal spaces can render the pelvic vascular networks and ureter visible, thereby mitigating the risk of damage to the ureter and major vessels.

Measurements and Main Results:

For frozen pelvis, surgery can be performed in a systematic way as followed:

Step 1: identify the pelvic ureter, and dissect the ovarian fossa (dissect the ovaries away from the ovarian fossa)

Step 2: “unbend” the retroverted uterus (separate the ovarian ligament away from the USL)

Step 3: dissect the “perirectal space” (separate the rectum away from USL)

Step 4: develop rectovaginal space (separate rectum from posterior cervix and vagina)

Once the normal anatomy is restored, the remaining excision of deep endometriosis (DE) can proceed with a minimal risk of injury to vital structures.

Conclusion:

Such a systematic approach within the retroperitoneal anatomical spaces can minimize bleeding, allows for minimal use of electrosurgery, and significantly reduces the risk of thermal injury to vital structures.