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AP X-RAY DEMONSTRATING APC TYPE 2

SYMPHYSEAL SEPARATION

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INLET VIEW DEMONSTRATING

SEPARATION OF THE SYMPHYSIS

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OUTLET VIEW

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The patient is prepped, such that the symphysis

is exposed inferiorly, the umbilicus superiorly and

the ASIS laterally.

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The incision begins two finger breadths

above the symphysis pubis.

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The incision begins two finger breadths

above the symphysis pubis.

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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

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Gelpi retractors are placed at the wound edges to

help identify Scarpas fascia and then the external

oblique and rectus fascia.

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The soft tissue is elevated superiorly and inferiorly

from the external oblique and rectus fascia with

the knife held essentially parallel with the body.

EXTERNAL

OBLIQUE

FASCIA

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The soft tissue is elevated superiorly and inferiorly

from the external oblique and rectus fascia with

the knife held essentially parallel with the body.

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The linea alba is easily identified by observing the

confluence of the fibers of the external oblique in the

midline.

FOOT

HEAD

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The dotted line is placed on the linea alba; the

fascia between the two rectus muscles is divided

sharply but only through the fascia.

HEAD

FOOT

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FOOTBlunt dissection between the rectus muscle is performed,

allowing protection of the peritoneum proximally, and bladder

and bladder neck distally.

RECTUS MUSCLE

HEAD

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HEAD

FOOTThe rectus is then divided with

a Bovi on top of the digit.

RECTUS MUSCLE

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HEAD FOOT

BLADDER

Once the rectus is split, a blunt retractor can be placed,

eventually holding back the bladder. In this figure, the

bladder region is visualized just proximal to the

symphyseal region underneath the rectus.

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FOOT

RECTUS

By lifting the rectus superiorly with the finger, a

Hohmann retractor can be placed through the

periosteum at the superior and proximal edge of

the superior ramus just lateral to the symphyseal

body.

HEAD

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FOOTHEAD

RECTUS

This is used to retract the rectus laterally.

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With the rectus being held laterally, a bovi can be

used to clean the superior surface of the superior

ramus in the area in which the plate will be placed.

SUPERIOR

RAMUS

FOOTHEAD

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SYMPHYSEAL

BODYRECTUS

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

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FOOT

HEAD

RECTUS

The Weber clamp is used 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.

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FOOT

HEAD

RECTUS

In the figure, the rectus muscles are allowed to fall back to

their neutral position so that the clamp can be pushed

through the superficial tissues distal to them.

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After the clamp is engaged, the symphysis is reduced

using the clamp. The clamp must be leaned towards

the feet in order to fully engage the tongs.

REDUCTION

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DEMONSTRATION OF THE

REDUCED SYMPHYSIS PUBIS

FOOT

HEAD

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If a standard 6-hole curved plate is used, a downward bend is

essential at the outer aspect of the plate as the middle

two screws on each side go into the symphyseal body while

the last screw goes into the ramus, lateral to

the pubic tubercle.

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The plate is also contoured in order to fit the bend of the

pelvis, which in men is usually an increased bend and in

women, a slight opening of the plate.

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DRILLING

ECCENTRICALLY

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 compression.

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The first screw that is placed is left somewhat proud

so as not to pull the plate over while the second screw

is placed in a similar fashion eccentrically in the hole.

DRILLED

ECCENTRICALLY

RAMUS

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The two screws are then tightened together,

allowing compression of the symphysis.

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Anatomic reduction of the symphysis is achieved

and all the screw holes are filled.

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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.

FOOTHEAD

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EDGE OF

RECTUS FASCIA

It is important not to tie through the entire rectus muscle,

as this may cause necrosis of part of that muscle.

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Completed running closure of the rectus fascia, with the

Hemovac drain emerging from within the rectus muscle.

HEAD FOOT

COMPLETE

REPAIR

HEMOVAC

DRAIN

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AP POSTOPERATIVE VIEW

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INLET VIEW

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OUTLET VIEW