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Photograph of another “frozen pelvis” in which the bowel is directly and densely adherent to the uterus (central round structure). There are active (red flame) endometriosis lesions on the surface of the uterus. It is often impossible to completely free the uterus from these sorts of adhesions to the overlying bowel in such a manner that postoperative adhesions are unlikely. Basically, these sorts of adhesions tend to be highly vascular and diffuse bleeding (often a slow oozing) from the sites of adhesiolysis generally lead to significant postoperative pelvic inflammation and adhesion formation. Complete hemostasis (control of bleeding) is sometimes dangerous since the site of most of the bleeding may be the surface of the bowel and cautery (coagulation) through heat or electricity may damage the bowel. One consideration that is sometimes effective when these sorts of friable adhesions are predominantly due to endometriosis is to pre-treat the patient with several months of a GnRH agonist (such as depo-lupron). After “drying up” the endometriotic lesions by suppressing ovarian function for 3-6 months the surgery is often much safer and easier technically.
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