Pfannenstiel Approach



- fracture medial to the iliopectineal eminence

- pubic diastasis

- fractures lateral to this prominence endangers the vascular sheath





- supine on radiolucent table

- IDC to empty bladder



- transverse incisions

- 15-20 cm in length and 2 cm above symphysis

- at the lateral edges of the incision take care to avoid the spermatic cords (or the round ligament in females)

- vertical incision is an alternative to the Pfannenstiel, in cases of concomitant abdominal trauma


Superficial Dissection    

- identification of the rectus

- normally, the rectus abdominus muscle tendons insert onto the anterior aspects of the pubis

- in acute case, rectus abdominis muscle has usually been avulsed and dissection is easy

- in chronic cases this dissection can be very difficult because of scar

- if the rectus has not be avulsed, then incise it, leaving a cuff of tissue attached to the pubis for later wound closure

- alternatively consider a vertical incision between the halves of the recti muscles, leaving the muscles attached to the pubis


Deep Dissection

- the dissection proceeds laterally until the external inguinal rings and the spermatic cords are identified

- exposure of symphysis

- identify the pubic eminences on either side of the symphysis

- the anterior portion of the symphysis is cleared of soft tissue



- spermatic cord

- bladder

- surgeon must stay on the skeletal plane to avoid injury to bladder                                    

- the bladder lies directly behind the symphysis pubis

- in males the bladder neck is attached to the posterior surface of the pubis by puboprostatic ligaments

- females in contrast, have a bladder that is in more contact with the pubococcygeal portions of the levator ani muscles

- with previous surgery or an old injury, the bladder may be scarred to the undersurface of the rectus and the symphysis pubis

- note proximity of symphysis both to spermatic cord & to NV structures


Ilioinguinal Approach



- anterior wall / anterior column acetabulum

- T type acetabular fractures

- periacetabular osteotomies



- inner pelvis / ilium to SIJ

- can expose outer surface by detaching abductors, but high risk of HO and disruption blood supply





- floppy lateral 0-30°

- drape to include contralateral iliac crest

- have to get right across pubis

- IDC to empty bladder

- radiolucent table


2 limb incision 

A.  Medial limb 

-  2-3 cm above symphysis pubis to ASIS

B.  Lateral limb 

- extends from ASIS along iliac crest

- start lateral & raise external oblique off iliac crest

- raise iliacus to expose SIJ


Superficial Dissection


Open inguinal canal

- divide external oblique along and proximal to inguinal ligament to the external inguinal ring

- need to leave flap to repair later

- spermatic cord (round ligament in females) is isolated & retracted medially

- laterally LFCN needs to be identified & protected


Open floor of inguinal canal

- internal oblique and transversalis off inguinal ligament

- again leave flap for attachment

- inferior epigastric artery crosses the floor of the inguinal canal at the medial border of the deep inguinal ring

- requires ligation

- symphysis can be exposed by releasing rectus


Deep Dissection


3 windows 

1.  Lateral window - lateral to iliopsoas

2.  Middle window - between psoas and vessels (key is iliopectineal fascia)

3.  Medial window - medial to vessels


Middle & Lateral window

- use peanuts to find external iliac vessels

- don't dissect out, simply identify, gently mobilise and place vessiloop around them

- mobilise psoas with femoral nerve, vessiloop

- find iliopectineal fascia

- finger up each side of fascia, is a vertical structure

- is the key to access from the false to the true pelvis

- divide it with scissors 

- retropubic space can be exposed by release of rectus


Exposure is then gained bw these 3 mobile tissue envelopes



- corona mortis

- anastomosis between external iliac and obturator artery

- behind superior pubic ramis

- present in about 10% of people

- can cause life threatening bleeding


Stoppa Approach



- anterior acetabular fracture





- radiolucent table in a supine position

- leg on the injured side draped freely

- both hips and knees slightly flexed to relax the iliopsoas muscle



- midline incision from umbilicus to symphysis


Superficial dissection

- open anterior rectus sheath vertically in midline

- open the preperitoneal space was opened and bluntly dissect to the symphysis pubis

- blunt dissect peritoneum from transversus

- mobilise peritoneal sac away from fracture site

- mobilise and protect CFA and CFV with vessiloop

- same with spermatic cord


Deep dissection

- subperiosteally dissect the superior pubic ramus

- identify and ligate corona mortis

- mobilise the psoas muscle and femoral nerve if needed

- expose the quadrilateral plate up to the medial SIJ