7.1.1 Principal Indications

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  Symphysis rupture

  
  
• 
  

  Medial pubic bone fractures

  
  
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  Symphysiodesis

7.1.2 Positioning and Incision

The operation is performed with the patient placed supine on a standard or carbon operating table. The leg on the injured side is draped to allow free movement, and the genital area must also be covered by sterile drapes. Depending on the injury pattern, the incision is either an extension of the vertical lower abdominal laparotomy incision or—in the case of isolated pelvic fractures—a transverse Pfannenstiel-type incision approximately one fingerbreadth above the usually palpable pubic tubercle ( Fig. 7.1 ). After the subcutaneous tissue has been divided, the linea alba is sought and split lengthwise ( Fig. 7.2 ). The bladder is then palpated cautiously and retracted cranially ( Fig. 7.3 ). Extra caution is required in revision surgery to avoid bladder injury because adhesions may be present. The muscle bellies of rectus abdominis are retracted laterally on both sides. The attachment to the pubic tubercle is often partially avulsed on one side. Complete division of the rectus abdominis is not usually necessary. The symphysis and medial parts of the pubic rami can now usually be visualized readily from the cranial aspect. The bladder can be retracted in posterosuperior direction with a broad spatula.

7.1.3 Wound Closure

During wound closure, the rectus abdominis is reattached with transosseous sutures, and the linea alba is closed securely to avoid the development of a hernia.

7.1.4 Dangers

Possible complications of this approach include bladder and peritoneal injuries and postoperative hernias.

7.2.1 Principal Indications

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  Pelvic ring fractures involving the ala of the ilium

  
  
• 
  

  Rupture of the sacroiliac joint

  
  
• 
  

  Revision surgery of the posterior pelvis

  
  
• 
  

  Arthrodesis of the sacroiliac joint

7.2.2 Positioning and Incision

The operation is performed with the patient placed supine on a standard or extension operating table. The leg on the injured side is draped to allow free movement. The anterior superior iliac spine and iliac crest are marked.

The approach consists of the first window of the ilioinguinal approach ( Fig. 7.4 ).

The incision extends along the iliac crest from its furthest end to the anterior superior iliac spine ( Fig. 7.5 ). For complete ilioinguinal access, the incision is extended to the symphysis. The tendinous attachment of the external oblique fascia on the iliac crest is divided somewhat lateral to the crest ( Fig. 7.6 ). Dissection then continues subperiosteally on the inside of the ala of the ilium into the iliac fossa as far as the linea terminalis and the anterior ligaments of the sacroiliac joint. Bleeding from the nutrient channels of the ala of the ilium may occur and must be controlled with bone wax. The iliacus is retracted anteromedially with wide Hohmann retractors. The sacroiliac joint and lateral parts of the sacrum can now be exposed ( Fig. 7.7 ). The lumbosacral trunk runs approximately 15–20 mm medial to the sacroiliac joint directly on the anterior surface of the sacrum and should be spared during dissection ( Fig. 7.8 ). If dissection is strictly subperiosteal, the risk of injuring the lumbosacral trunk can be minimized.

7.2.3 Wound Closure

The wound is closed in layers with reattachment of the external oblique fascia to the iliac crest.

7.2.4 Dangers

Possible complications of this approach are bleeding from the nutrient channels of the ala of the ilium, injuries to the lumbosacral trunk, especially the L5 root, which courses on the anterior surface of the lateral sacrum, and also a hernia if the fascia is incompletely reattached.

Injury to the lateral cutaneous nerve of the thigh may also occur.