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1、AP X-RAY DEMONSTRATING APC TYPE 2SYMPHYSEAL SEPARATION,INLET VIEW DEMONSTRATING SEPARATION OF THE SYMPHYSIS,OUTLET VIEW,The patient is prepped,such that the symphysis is exposed inferiorly,the umbilicus superiorly and the ASIS laterally.,The incision begins two finger breadths above the symphysis pu
2、bis.,The incision begins two finger breadths above the symphysis pubis.,Frequently,one of the rectus heads is avulsed from one of the symphyseal bodies.Occasionally there is a split in the rectus fascia.,RECTUS MUSCLE,Gelpi retractors are placed at the wound edges to help identify Scarpas fascia and
3、 then the external oblique and rectus fascia.,The soft tissue is elevated superiorly and inferiorlyfrom the external oblique and rectus fascia withthe knife held essentially parallel with the body.,EXTERNALOBLIQUEFASCIA,The soft tissue is elevated superiorly and inferiorlyfrom the external oblique a
4、nd rectus fascia withthe knife held essentially parallel with the body.,The linea alba is easily identified by observing the confluence of the fibers of the external oblique in the midline.,FOOT,HEAD,The dotted line is placed on the linea alba;the fascia between the two rectus muscles is dividedshar
5、ply but only through the fascia.,HEAD,FOOT,FOOT,Blunt dissection between the rectus muscle is performed,allowing protection of the peritoneum proximally,and bladder and bladder neck distally.,RECTUS MUSCLE,HEAD,HEAD,FOOT,The rectus is then divided with a Bovi on top of the digit.,RECTUS MUSCLE,HEAD,
6、FOOT,BLADDER,Once the rectus is split,a blunt retractor can be placed,eventually holding back the bladder.In this figure,thebladder region is visualized just proximal to the symphyseal region underneath the rectus.,FOOT,RECTUS,By lifting the rectus superiorly with the finger,a Hohmann retractor can
7、be placed through the periosteum at the superior and proximal edge of the superior ramus just lateral to the symphyseal body.,HEAD,FOOT,HEAD,RECTUS,This is used to retract the rectus laterally.,With the rectus being held laterally,a bovi can beused to clean the superior surface of the superiorramus
8、in the area in which the plate will be placed.,SUPERIORRAMUS,FOOT,HEAD,SYMPHYSEALBODY,RECTUS,With the legs held together and the retractors in place,the symphyseal separation is already partly reduced.The sucker is within the symphyseal separation.,FOOT,HEAD,FOOT,HEAD,RECTUS,The Weber clamp is used
9、to reduce the symphysis.It should be placed superficial and distal to the rectus insertion rather than dissecting the rectus subperiosteally from the front of the pelvis.,FOOT,HEAD,RECTUS,In the figure,the rectus muscles are allowed to fall back to their neutral position so that the clamp can be pus
10、hed through the superficial tissues distal to them.,After the clamp is engaged,the symphysis is reducedusing the clamp.The clamp must be leaned towardsthe feet in order to fully engage the tongs.,REDUCTION,DEMONSTRATION OF THE REDUCED SYMPHYSIS PUBIS,FOOT,HEAD,If a standard 6-hole curved plate is us
11、ed,a downward bend isessential at the outer aspect of the plate as the middletwo screws on each side go into the symphyseal body whilethe last screw goes into the ramus,lateral to the pubic tubercle.,The plate is also contoured in order to fit the bend of thepelvis,which in men is usually an increas
12、ed bend and inwomen,a slight opening of the plate.,DRILLINGECCENTRICALLY,The screws immediately adjacent to the symphysis are placed angling slightly away from the symphysis,paralleling the posterior aspect of the symphyseal body and eccentrically within the plate screw holes to allow for some compr
13、ession.,The first screw that is placed is left somewhat proudso as not to pull the plate over while the second screwis placed in a similar fashion eccentrically in the hole.,DRILLEDECCENTRICALLY,RAMUS,The two screws are then tightened together,allowing compression of the symphysis.,Anatomic reductio
14、n of the symphysis is achievedand all the screw holes are filled.,RECTUS,After fixation,a Hemovac drain should be placed in the space of Retzius,as demonstrated here.Once the wound is thoroughly irrigated and the drain is placed,the rectus fascia is closed.,FOOT,HEAD,EDGE OFRECTUS FASCIA,It is important not to tie through the entire rectus muscle,as this may cause necrosis of part of that muscle.,Completed running closure of the rectus fascia,with theHemovac drain emerging from within the rectus muscle.,HEAD,FOOT,COMPLETE REPAIR,HEMOVACDRAIN,AP POSTOPERATIVE VIEW,INLET VIEW,OUTLET VIEW,
