Anterior Approach to Pubic Symphysis indications:

  • The anterior approach to pubic symphysis is a direct approach that is used almost exclusively for the open reduction and internal fixation of a ruptured symphysis or internal fixation of a displaced fracture of the superior pubic ramus.
  • Other uses include biopsy of tumors and treatment of chronic osteomyelitis.

Position of the Patient

  • Place the patient supine on the operating table.

Landmarks and Incision

  • Landmarks:
    1. The superior pubic ramus.
    2. pubic tubercles .
    3. The pubic symphysis will be palpable (as a gap) only in cases of rupture.
  • Incision:
    • Make a 15-cm curved incision in the line of the skin crease, centering it about 1 cm above the pubic symphysis.
Anterior Approach to Pubic Symphysis

Internervous plane

  • There is no Internervous plane for the anterior approach to pubic symphysis, because the rectus abdominis muscles receive a segmental nerve supply, they are not denervated, even though they are divided by this approach.

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 that run up from below across the operative field.
  • Then, divide the rectus sheath transversely, about 1 cm above the symphysis pubis.
  • The two rectus abdominal muscles now are visible.
  • In most cases of rupture of the symphysis pubis, one of these muscles will have been detached from its insertion into the pubic symphysis.
  • Divide the remaining muscle a few millimeters above its insertion into the bone.

Deep dissection

  • Retract the cut edges of the rectus abdominal muscles superiorly to reveal the symphysis and pubic crest.
  • If access to the back of the symphysis is required, use the fingers or a swab to push the bladder gently off the back of the bone.
  • Palpation of the posterior surface of the body of the pubis is useful to identify the correct direction for the insertion of screws.
  • This dissection is very easy to perform unless adhesions have formed due to damage to the bladder. Such adhesions make it difficult to open up this potential space (the preperitoneal space of Retzius).
  • The pubic symphysis and superior pubic rami now are exposed adequately for internal fixation.

Approach Extension

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

Dangers

The structures at risk during anterior approach to pubic symphysis include:

  1. The Bladder:
    • The bladder may have been damaged during the trauma. If so, adhesions will have developed between the amaged 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.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition