Pfannenstiel approach

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Introduction

Indications

  • ORIF of a ruptured symphysis.
  • Biopsy of tumors.
  • Treatment of chronic osteomyelitis.

Position of patient

  • Position the patient supine on a flouro table.
  • Insert a urethral catheter before surgery.

Landmarks and incision

Landmarks

  • The superior pubic ramus and pubic tubercles.
  • The pubic symphysis will be palpable (as a gap) only in cases of rupture.

Incision

  • A 15-cm curved incision in the line of the skin crease, centered about 1 cm above the pubic symphysis.

Internervous plane

No true internervous plane.

Superficial dissection

  • Incise the subcutaneous fat in the line of the skin incision, deepening the incision down to the anterior portion of the rectus sheath.
  • Identify, ligate, and divide the superficial epigastric artery and vein.
  • Divide the rectus sheath transversely 1 cm above the symphysis pubis to reveal the rectus abdominis muscles and pyramidalis.
  • In acute case, the rectus abdominis muscle has usually been avulsed and dissection is easy. In chronic cases, this dissection can be very difficult because of scar and adhesion.
  • Divide the remaining muscle a few millimeters above its insertion into the bone.
  • The dissection proceeds laterally, until the external inguinal rings and the spermatic cords in males and round ligament in females are identified.

Deep dissection

  • Divide the rectus muscles 1 cm above their insertion and retract their cut edges superiorly to reveal the superior ramus of the pubis.
  • Open the plane behind the symphysis pubis, using your finger as a blunt dissector.
  • The pubic symphysis and superior pubic rami now are exposed adequately for internal fixation.

Dangers

Urinary bladder

  • The bladder may have been damaged during the trauma and adhesions will have developed between the damaged bladder and the back of the pubis. Mobilization of the space of Retzius, therefore, may lead to inadvertent bladder rupture.
  • If fixation is considered in the presence of urologic damage, it is best to operate in conjunction with an experienced urologic surgeon.

Proximity of symphysis to the spermatic cord & the NV structures

  • At the lateral edges of the incision, take care to avoid the spermatic cords (or the round ligament in females)

How to enlarge the approach

  • The approach can be extended laterally to expose the entire anterior column of the acetabulum and the inner wall of the ilium through an extended ilioinguinal approach.

Figures

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