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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • right angle clamp
  • Sofield or other right angle retractors

2

Room setup and equipment

  • standard OR table, but may use radiolucent table if this is being done as part of a SEMLS procedure (single event multilevel surgery)
  • headlight may be used for large patients

3

Patient positioning

  • supine
  • place a bump under the ipsilateral hip to elevate it in unilateral cases
G

Skin Incision

1

Make the oblique incision

  • localize and mark out artery on skin prior to incision
  • make and oblique 5 cm anterior bikini incision just distal to the ASIS
  • start the incision just distal to the the ASIS and extend the incision distally and medially
H

Deep Dissection

1

Identify the tensor fascia lata/ sartorius interval

2

Open the Tensor fascia lata/sartorius interval

  • place a hemostat or tenotomy scissors into soft spot below the ASIS and open the fascia
  • open and identify fat stripe that is associated with the lateral femoral cutaneous nerve
  • isolate and protect the nerve.
  • deep to the interval is the rectus femoris tendon.
  • dissection is carried out medial to this and the pelvic brim is palpated
  • flex the hip and the psoas tendon and muscle can be identified
I

Psoas Identification

1

Expose the psoas tendon

  • flex the hip
  • place a sofield retractor under the psoas muscle to elevate it
  • slide the sofield retractor along the undersurfrace of the psoas muscle and the psoas tendon will roll into view
  • use a tenotomy to open the fascia over the psoas tendon
  • place a right angle retractor around psoas tendon islolating it from the muscle

2

Identify the psoas tendon with 3 essential tests prior to cutting

  • #1 identify the muscle fibers entering the psoas tendon
  • #2 confirm it is the psoas tendon by noting the musculotendinous junction tightens with internal rotation of the hip
  • #3 make sure the leg does not "jump" with brief stimulation of the tendon with electrocautery
J

Psoas Lengthening

1

Perform lengthening

  • retract the muscle fibers
  • divide the tendon with electrocautery
  • be sure to leave the muscle intact
  • identify any inflexible tissue and divide it
K

Wound Closure

1

Wound closure

  • close the subcutaneous tissue with interrupted 2.0 absorbable suture
  • close the skin with a running absorbable 3.0 monofilament suture
Postoperative Patient Care
 

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