Dr (Major) Parthasarathy S

Junior Resident,MS Orthopaedics

Stanley Medical College,Chennai
Ref : Campbell’s operative orthopaedics 13th edn
Rockwood and Green’s fractures in adults 8th edition
Surgical exposures in orthopaedics 4th edn Hoppenfeld
Netter’s concise orthopaedic anatomy
AO Foundation official website
 Letournal 1960
 It provides exposure of the inner aspect of
the innominate bone from the sacroiliac joint
to the pubic symphysis
 Hip abductors not disturbed
 rapid post op rehabilitation
 Acetabular articular surface not exposed-
disadvantage
•in dark brown: Direct access
•in light brown: Secondary access for
clamp placement or limited
visualization
 anterior wall and anterior column # as well
as associated anterior plus posterior hemi-
transverse patterns.
 Majority of both column fractures
 Transverse or T-shape fracture
 The surgical exposure requires development of
three wound intervals
 Lateral
 Middle
 medial
 Mobilization of the femoral vessels and nerve, as
well as the spermatic cord (male) or round
ligament (female), is key to the development of
these intervals.
 POSITION
 Supine
# table
 Pin traction/trochanteric traction
 Traction avoided in contralateral pubic ramus #
 Skin incision
 Begin 3cm above pubic symphysis
 Carry laterally across lower abdomen
 Asis
 Till jn of middle & post 1/3rd of iliac crest
 Begin by exposing the internal iliac fossa.
Release the external oblique insertion onto the
iliac crest, taking care to leave a thick fascial/
periosteal cuff to facilitate repair.
Initially, leave the tissues attached to the
anterior superior iliac spine.
 In continuity with this release, expose the
internal iliac fossa subperiosteally by mobilizing
the iliacus muscle.
Pack the fossa with a sponge.
 Next, the external oblique aponeurosis is
incised from the anterior superior iliac spine
(ASIS) to the lateral border of the rectus
sheath, passing cranial to the external inguinal
ring.
 Release the muscular attachment from the
inguinal ligament
 The spermatic cord (or round ligament) is
mobilized in the medial aspect of the wound.
 Medially the transversus abdominis is then
released from the inguinal ligament, usually
taking 1-2 mm of the ligament with the tendon.
 This release begins at the anterior superior iliac
spine and progresses medially to the conjoint
tendon of the internal oblique, and the pubic
tubercle.
 Care must be taken during this portion of the
procedure to protect the ilioinguinal nerve which
normally lies just proximal to the inguinal
ligament after penetrating the abdominal wall
 The lateral cutaneous nerve of the thigh is
usually encountered just deep to the conjoint
tendon (of the internal oblique and the
transversus abdominis) approximately 1-2 cm
medial to the anterior superior iliac spine.
 This nerve can usually be preserved if it is
mobilized as it exits the abdominal wall and
enters the fascia of the thigh.
 The anterior aspect of the iliopsoas muscle is
thus exposed in the lateral portion of the
wound with the femoral nerve lying on its
anteromedial surface.
 Divide conjoint tendon& rectus abdominis at
their insertion on pubis to open retropbic
space
 Structures beneath inguinal lig lie in 2
compartment
 Lacuna muscularom
 Lateral
 Contains iliopsoas muscle,femoral nerve & lateral
cutaneous nerve
 Lacuna vasorum
 Medial
 Contans external iliac vessels & lymphatics
 Iliopectineal fascia/ psoas fascia seperates
both
 Carefully elevate vessels and lymphatics
from fascia & retract medially
 Psoas fascia divided till pectineal eminence
 Iliopsoas freed from pelvic brim
 Bunt finger dissection used to disscect external
iliac vessels & lymphatics and protected
 Obturatory artery & nerve medial posterior to
above structures
The 3 windows of the ilioinguinal approach
can now be fully exploited
First window
 Ecompasses the entire internal iliac fossa from
the sacroiliac joint posteriorly to the
iliopectineal eminence anteriorly.
 This window is optimized with hip flexion to
relax the iliopsoas
 Medial retraction usually requires placement of
retractors on the quadrilateral surface.
 Second window
 Provides access to the pelvic brim and
quadrilateral surface from the sacroiliac joint to
the lateral third of the superior pubic ramus
 Medial retraction of the femoral vessels should
be gentle and must be carefully monitored.
 Third window
 The most limited leaves the ipsilateral rectus
insertion attached and visualization is provided
between the rectus and the spermatic cord (or round
ligament)
 Alternatively, if the fracture pattern requires, the
entire medial portion of the superior ramus and
symphysis can be visualized by release of the
ipsilateral rectus insertion.
 The same visualization can be achieved by leaving the
rectus attached and splitting the rectus heads in the
midline. With the rectus still attached, retraction is
carried out posterior to the rectus with a Hohmann
retractor placed along the superior ramus.
 Wound closure
 Place drains in the space of Retzius and anterior
internal iliac fossa
 Layered closure then begins with repair of the conjoint
tendon to the inguinal ligament
 The external oblique aponeurosis and the rectus sheath
are then repaired, followed by secure reattachment of
the abdominal wall origin to the iliac crest, in the
lateral portion of the incision
 A hernia-free repair, and avoidance of entrapment of
the spermatic cord should be achieved
 Subcutaneous drains may be inserted
 Finally, perform an appropriate subcutaneous and skin
closure
 Intrapelvic approach
 Hirvensalo et al 1993 – first described
 Cole et al described similar approach 1994
 Substitute-ilioinguinal approach
 Treatment of #
 Ant wall
 Ant column
 Transverse
 T type
 Post hemitransverse
 Both column
 Recently lateral window combined
 Obturator nerve should be protected
 Advantage
 Improved quadrilateral surface exposure & post
column
 Minimise dissection( avoid middle window)
 Iliac vessels dissection not required
 Disadvantage
 Lack of acess to middle window
 Limitng factor in exposure-extent of vertical
dissection of rectus not lateral dissection
 Position : supine
 Skin insicion
 pfannensteil or
 Midline incision starting 1cm inf to pubic symphysis ending
2-3 cm inf to umbilicus
 Sc tissue dissected in line with skin incision
 Fascia over both rectus muscle exposed
 Fascia incise along linea alba
 Rectus muscle both bellies retracted laterally
 In proximal aspect do not enter peritoneum
 Entire approach periperitoneal space
 Loosely packed wet sponge in retropubic space to
protect bladder
 The medial part of the rectus muscle is partly
detached from the upper and anterior part of the
symphysis
 The thick periosteum from the superior pubic
bone is dissected sharply, allowing for deeper
blunt dissection.
 At the beginning, dissection should be
enlarged also on the anterior part of the
symphysis.
 The upper border of the superior pubic
ramus is identified (pecten pubis) and the
dissection is carried laterally along the pelvic
brim. The iliopectineal fascia is detached
from the pelvic brim
 Dissecting carefully along the medial surface of
the superior ramus, the corona mortis vessels are
identified and ligated (or clipped) as necessary
 Dissection of the periosteum is continued further
laterally following the upper border of the superior
pubic bone to the direction of the pelvic brim
exposing the beginning of the iliopectineal
eminence
 At this point the beginning of the
iliopectineal arch should be dissected from
the bone. This enables the elevation of the
femoral vessels and nerve.
 The dissection is continued subperiosteally
more laterally following the upper border of
the pelvic brim.
 At this point the entire internal surface of
the superior pubic ramus has been exposed
adequately for plate fixation
 At this level, the obturator neurovascular bundle
is crossing the quadrilateral surface. In some
cases it should be mobilized. A spatula or
malleable retractor is used to protect the
obturator neurovascular bundle and pelvic floor.
 With a Cobb elevator, the periosteum and
obturator internus is elevated and the
quadrilateral surface can be sufficiently exposed.
 One Hohmann retractor should be put in the
middle part of the superior pubic ramus and
another curved Hohmann retractor is placed on
the posterior top of the acetabulum on the iliac
part of the pelvic brim.
 Great care should be taken not to injure the
external iliac vein which may be in close
proximity to the elevators
 In some rare cases, the internal iliac artery
bifurcates very distally and makes the dissection of
the posterior part of the quadrilateral surface risky
and limits the further dissection
 The intrapelvic space may be drained.
 The midline incision in the rectus abdominis and
superficial tissues are closed in layers