What is Frozen Pelvis?
Frozen pelvis is a surgical condition where severe adhesive disease causes the pelvic organs (uterus, ovaries, fallopian tubes, bowel, and bladder) to become distorted and tethered together, obliterating normal anatomical landmarks and surgical planes. 1, 2
Definition and Pathophysiology
Frozen pelvis occurs when extensive adhesions bind pelvic structures together, making less than 20% of the ovarian surface visible and rendering the remainder bound down with significant adhesions. 3
The condition results from severe adhesive processes that distort normal pelvic anatomy, creating a situation where organs are "frozen" in abnormal positions relative to each other. 1, 2
This anatomical distortion obscures normal surgical landmarks and planes, making dissection extremely difficult and significantly increasing the risk of intraoperative and postoperative complications. 2
Common Etiologies
Severe endometriosis is the most common cause, particularly stage IV disease with extensive pelvic involvement. 1, 2
Pelvic inflammatory disease (PID) with chronic sequelae can lead to frozen pelvis through extensive adhesion formation. 3
Ruptured tubo-ovarian abscess creates dense adhesions that can result in frozen pelvis anatomy. 4
History of multiple abdominal surgeries or presence of abdominal mesh may contribute to the condition. 4
Clinical Implications
Reproductive Impact
Patients with frozen pelvis demonstrate significantly impaired ovarian response to hyperstimulation protocols in IVF programs, with higher rates of cancelled oocyte retrievals due to poor estradiol response. 3
These patients show significantly lower rates of estradiol rise, lower peak estradiol values, longer time to respond to hyperstimulation, and fewer follicles formed compared to patients with adhesion-free ovaries. 3
The disruption of ovarian blood supply or mechanical pressure from significant adhesions likely prevents adequate follicular response. 3
Lower numbers of oocytes are obtained, though fertilization rates remain comparable to controls. 3
Surgical Challenges
The distorted anatomy makes identification of critical structures (ureters, bowel, bladder, vessels) extremely hazardous without systematic restoration of normal anatomical planes. 1, 2
Surgeons must use specific techniques including systematic ureterolysis, opening of retroperitoneal spaces, and dissection of pararectal spaces (Okabayashi's space) before attempting definitive procedures. 1, 2
The condition requires advanced surgical skills and a reproducible step-by-step approach to safely restore anatomy before addressing the underlying pathology. 2
Important Distinction
This gynecologic condition should not be confused with "frozen abdomen" in trauma surgery, which refers to a complication of open abdomen management where extensive adhesions prevent fascial closure. 5 The term "frozen pelvis" specifically describes the gynecologic condition related to severe pelvic adhesive disease from endometriosis or infection, not traumatic pelvic injuries or their sequelae.