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
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