THE DILEMMAS OF THE

LAPARASCOPIC SURGICAL SOLUTION

OF THE PELVIS FROZEN AT
INFERTILITY SURGERY WITHOUT
BOUNDARIES
Bojan Mranov
The General hospital in Subotica, Department of Gynecology
and Obstetrics

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Definition
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 .

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 Douglass pouch, the sticking of
the ovaries to their pits, the passage of the fallopian
(uterine) tube and some complications have been
analysed.

Cases

endometriosis

infections

26

17

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.

average age

prim. infertility

sec. infertility

endometriosis

34

16

infection

26

Transcience before therapy

proximal

distal

intranscient

endometriosis

15

infection

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

proximal

distal

intranscient

endometriosis

16

11

infection

Distribution of adhesions

excellent

good

better

no
improvement

endometriosis

10

infection

Accessibility to the Douglass pouch

excellent

good

better

bad

endometriosis

infection

Sticking of the ovaries to their pit

excellent

good

better

no
improvement

endometriosis

infection

Complications

re-laporoscopy

injury

transfusion

endometriosis

infection

1 (sigmoid colon )

The approach to the operative treatment of

pelvis frozen requires :
sample analysis
medicolleguial aspect
making plans for solving individual anatomic

problems
foresight of possible iatrogenic damages
foresight of the need of a multidisciplinary team
accepting 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.

Conclusion
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.

Thank You