Stoppa approach

Introduction

- It is an anterior intrapelvic (AIP) extraperitoneal approach through the rectus abdominis muscle for internal fixation of pelvic and acetabular fractures.

- This approach provides direct access to

• The pubis
• The posteriorsurface of the ramus
• The quadrilateral surface
• The pubic eminence,and the infrapectineal surface
• The sciatic buttress,sciatic notch
• The anterior sacroiliac joint
• Improved exposure of the quadrilateral surface and posterior column

- Indication :

• Anterior wall
• Anterior column
• Associated anterior column and posterior hemitransverse fractures
• Certain both-column, T-shaped, and transverse fractures
• Useful for fractures that involve the quadrilateral surface with or without comminution and medial dislocation of the femoral head

- Contraindication :

• Fractures with posterior-only patterns (eg, posterior wall, posterior column, transverse) that exit below the ischial spine.
• A history of cesarean section, hysterectomy, bladder injury, or bladder surgery may increase the risk of cystotomy and contamination or infection and may preclude the AIP and any other anterior approach.
• A history of prostatectomy may increase the risk of perioperative bleeding because of excessive scarring of the structures in the Retzius space.
• Neither a history of previous hernia surgery nor current hernia is a contraindication to the AIP approach.

Position of patient

- The patient is placed supine on a radiolucent operating table that allows adequate visualization on AP and Judet radiographs.

- A table that facilitates lateral traction of the hip is helpful in eliminating deforming forces on the anterior column and quadrilateral surface, and the ipsilateral hip and knee are maintained in slight flexion using traction on the flexed leg or a radiolucent triangle.

- A Foley catheter is used to protect the bladder, improve visualization, and monitor fluid balance.

- Typically, the surgeon stands on the contralateral side to improve visualization of and access to the true intrapelvic cavity.

Landmarks and incision

- Symphysis pubis and ASIS are the landmark for your incision.

- A transverse Pfannenstiel incision is made 1 to 2 cm superior to the pubic symphysis this is carried short of each external inguinal ring.

- For lateral window ,in case you need,  an incision is made along the iliac crest, starting ~2 cm posterior to the ASIS, following the iliac crest posteriorly.

Internervous plane

No true internervous Plane

Superficial dissection

- Dissection is carried down through the skin and subcutaneous tissue to the level of the rectus fascia.

- The rectus fascia is split in line with its fibers, and the transversalis fascia is incised just superior to the pubic symphysis.

- Lateral dissection is discouraged because of the risk of injury to the spermatic cord or round ligament as they exit the external ring.

- Blunt dissection of the Retzius space is performed. This space is packed with laparotomy sponges to protect the urinary bladder and urethra*.*

Deep dissection

- Subperiosteal dissection is performed along the pubis, superior pubic ramus, posterior surface of the ramus, and pelvic brim up into the internal iliac fossa.

- A pointed Hohmann retractor may be placed over the pubic tubercle to reflect the rectus musculature.

- As the dissection is extended toward the acetabulum, a Deaver retractor or malleable retractor is used to protect and elevate the external iliac vessels and the iliopsoas muscle.

- The vascular anastomoses between the external iliac and obturator vessels (ie, corona mortis) are encountered as the artery and vein course over the superior ramus traveling toward the obturator foramen. These vessels   must be ligated or clipped to advance the dissection farther along the pelvic brim and quadrilateral surface.

- Additional exposure is obtained with distal extension of periosteal dissection along the pelvic brim. The iliopectineal fascia is detached over the anterior column and the dome of the acetabulum. A Taylor or Deaver retractor may be placed under the iliopsoas muscle to protect the external iliac vessels. Dissection is continued toward the anterior aspect of the sacroiliac joint to expose the entire pelvic brim.

- The quadrilateral surface and the medial aspect of the posterior column are exposed. The obturator neurovascular bundle is identified in the fat medial to the internal obturator muscle . This bundle may be isolated and protected with a narrow malleable retractor placed gently in the sciatic notch or between the quadrilateral surface and the internal obturator muscle . Lateral retraction of the femoral head with a trochanteric traction pin facilitates exposure and reduction by eliminating deforming forces on the medially displaced fracture.

- Anterior column fractures that exit the iliac crest and fractures that cannot be adequately reduced and/or stabilized using the AIP window may be accessed using the lateral window of the ilioinguinal approach.

• An incision is made along the iliac crest to expose the insertion of the oblique abdominal muscles.
• These muscles are released to allow dissection over the crest into the internal iliac fossa.
• The iliac muscle is elevated subperiosteally, exposing the iliac fossa to the pelvic brim as well as the anterior aspect of the sacroiliac joint.
•  Frequently, nutrient vessel foramina are encountered along the internal iliac fossa; these can be a source of brisk hemorrhage. Bone wax is applied to the foramina to control bleeding.
• A Ganz or blunt Hohmann retractor may be placed carefully into the sciatic notch or along the quadrilateral surface to improve visualization.
• This adjunct lateral window facilitates reduction of high anterior column fractures and placement of posterior column lag screws

Dangers

• 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.
• 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.

Figures