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Introduction
  • Indications
    • acetabular fractures
    • pelvic ring injuries
  • Approach provides access to 
    • pubic body
    • superior pubic ramus
    • pubic root
    • ilium above and below the pectineal line
    • quadrilateral plate 
    • medial aspect of the posterior column
    • sciatic buttress
    • anterior sacroiliac joint
    • upper ilium and iliac crest
Preparation & Positioning
  • Preparation
    • a radiolucent table is required
    • Foley catheter is required to improve visualization
  • Position
    • supine 
    • ipsilateral limb is draped free into the field
    • hip and knee are flexed to relax the ilipsoas/femoral neurovascular bundle
    • operating surgeon is on the opposite side of the table
Approach
  • Incision
    • a transverse incision is made approximately 2 cm above the symphysis
      • this is carried short of each external inguinal ring
    • for the "lateral window", an incision is made along the iliac crest, starting ~2 cm posterior to the ASIS, following the iliac crest posteriorly
  • Superficial dissection
    • subcutaneous tissue and rectus fascia are incised transversely 
    • the pyrimidalis muscle is released and tagged for later repair 
    • the rectus abdominus fascia is split along the linea alba 
    • the transversalis fascia is opened superior to the pubic symphysis
      • this opens the potential space of Retzius (space behind the symphysis and anterior to the bladder) 
    • for the "lateral window", the insertion of the external oblique is released, permitting dissection into the internal iliac crest fossa (requires elevation of the iliacus muscle)
  • Deep dissection
    • the origin of the rectus abdominus muscle is released off the posterior pubic rami but maintained anteriorly
      •  a Hohmann retractor is used to retract the rectus anteriorly
    • the iliopectineal fascia is released to enter the true pelvis
    • anastamoses between the external iliac and obturator vessels (corona mortis) should be identified along the superior pubic ramus and ligated 
    • the iliopsoas can now be subperiosteally elevated, and a retractor is used to retract the iliopsoas and external iliac vessels
      • the entire pelvic brim should be visualized at this time 
    • the obturator neurovascular bundle is exposed and protected as the quadrilateral surface and posterior column are dissected
Dangers & Complications
  • Obturator nerve and vessels
    • retracted carefully during exposure of the quadrilateral plate and posterior column
  •  Corona mortis
    • these anastamoses must be ligated as they appear on the lateral 1/3 of the superior pubic ramus
    • they are nearly universally present but vary significantly in size
  • External iliac vessels
    • exposed and retracted early in the exposure; must be mobilized to expose the iliac fossa and false pelvis
  • Bladder
    • Foley catheter limits injury; placement of a malleable retractor anterior to bladder also helps protect

 

 

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