Approaches
Pfannenstiel
Ilioinguinal
Stoppa
Pfannenstiel Approach
Indications
- fracture medial to the iliopectineal eminence
- pubic diastasis
- fractures lateral to this prominence endangers the vascular sheath
Technique
Position
- supine on radiolucent table
- IDC to empty bladder
Incision
- transverse incisions
- 15-20 cm in length and 2 cm above symphysis
- at the lateral edges of the incision take care to avoid the spermatic cords (or the round ligament in females)
- vertical incision is an alternative to the Pfannenstiel, in cases of concomitant abdominal trauma
Superficial Dissection
- identification of the rectus
- normally, the rectus abdominus muscle tendons insert onto the anterior aspects of the pubis
- in acute case, rectus abdominis muscle has usually been avulsed and dissection is easy
- in chronic cases this dissection can be very difficult because of scar
- if the rectus has not be avulsed, then incise it, leaving a cuff of tissue attached to the pubis for later wound closure
- alternatively consider a vertical incision between the halves of the recti muscles, leaving the muscles attached to the pubis
Deep Dissection
- the dissection proceeds laterally until the external inguinal rings and the spermatic cords are identified
- exposure of symphysis
- identify the pubic eminences on either side of the symphysis
- the anterior portion of the symphysis is cleared of soft tissue
Dangers
- spermatic cord
- bladder
- surgeon must stay on the skeletal plane to avoid injury to bladder
- the bladder lies directly behind the symphysis pubis
- in males the bladder neck is attached to the posterior surface of the pubis by puboprostatic ligaments
- females in contrast, have a bladder that is in more contact with the pubococcygeal portions of the levator ani muscles
- with previous surgery or an old injury, the bladder may be scarred to the undersurface of the rectus and the symphysis pubis
- note proximity of symphysis both to spermatic cord & to NV structures
Ilioinguinal Approach
Indications
- anterior wall / anterior column acetabulum
- T type acetabular fractures
- periacetabular osteotomies
Access
- inner pelvis / ilium to SIJ
- can expose outer surface by detaching abductors, but high risk of HO and disruption blood supply
Technique
Position
- floppy lateral 0-30°
- drape to include contralateral iliac crest
- have to get right across pubis
- IDC to empty bladder
- radiolucent table
2 limb incision
A. Medial limb
- 2-3 cm above symphysis pubis to ASIS
B. Lateral limb
- extends from ASIS along iliac crest
- start lateral & raise external oblique off iliac crest
- raise iliacus to expose SIJ
Superficial Dissection
Open inguinal canal
- divide external oblique along and proximal to inguinal ligament to the external inguinal ring
- need to leave flap to repair later
- spermatic cord (round ligament in females) is isolated & retracted medially
- laterally LFCN needs to be identified & protected
Open floor of inguinal canal
- internal oblique and transversalis off inguinal ligament
- again leave flap for attachment
- inferior epigastric artery crosses the floor of the inguinal canal at the medial border of the deep inguinal ring
- requires ligation
- symphysis can be exposed by releasing rectus
Deep Dissection
3 windows
1. Lateral window - lateral to iliopsoas
2. Middle window - between psoas and vessels (key is iliopectineal fascia)
3. Medial window - medial to vessels
Middle & Lateral window
- use peanuts to find external iliac vessels
- don't dissect out, simply identify, gently mobilise and place vessiloop around them
- mobilise psoas with femoral nerve, vessiloop
- find iliopectineal fascia
- finger up each side of fascia, is a vertical structure
- is the key to access from the false to the true pelvis
- divide it with scissors
- retropubic space can be exposed by release of rectus
Exposure is then gained bw these 3 mobile tissue envelopes
Danger
- corona mortis
- anastomosis between external iliac and obturator artery
- behind superior pubic ramis
- present in about 10% of people
- can cause life threatening bleeding
Stoppa Approach
Indications
- anterior acetabular fracture
Technique
Position
- radiolucent table in a supine position
- leg on the injured side draped freely
- both hips and knees slightly flexed to relax the iliopsoas muscle
Incision
- midline incision from umbilicus to symphysis
Superficial dissection
- open anterior rectus sheath vertically in midline
- open the preperitoneal space was opened and bluntly dissect to the symphysis pubis
- blunt dissect peritoneum from transversus
- mobilise peritoneal sac away from fracture site
- mobilise and protect CFA and CFV with vessiloop
- same with spermatic cord
Deep dissection
- subperiosteally dissect the superior pubic ramus
- identify and ligate corona mortis
- mobilise the psoas muscle and femoral nerve if needed
- expose the quadrilateral plate up to the medial SIJ