Dr. Claude Sagi: Full Sequence, Anterior Intra-Pelvic Approach

00:36:00
https://www.youtube.com/watch?v=d2aEN6EkmFo

摘要

TLDRThe video outlines a surgical procedure focusing on the dissection and exposure of the rectus fascia and surrounding pelvic structures. It details the careful approach needed to avoid damaging critical nerves and blood vessels, particularly the obturator nerve and external iliac vessels. The procedure involves mobilizing the rectus muscle, releasing the iliopectineal fascia, and accessing the quadrilateral surface and posterior column of the pelvis. The use of retractors and screws for stabilization is emphasized, along with the importance of maintaining proper visualization and avoiding complications during the surgery.

心得

  • 🛠️ Detailed surgical guide on pelvic surgery
  • ⚠️ Importance of avoiding nerve damage
  • 🔍 Mobilizing rectus muscle for better access
  • 📏 Releasing iliopectineal fascia is crucial
  • 🧠 Managing obturator nerve during dissection
  • 🔗 Accessing quadrilateral surface for stabilization
  • 🔒 Using retractors and screws for support
  • 💡 Suction retractor improves visualization
  • 💪 Mobilizing iliacus muscle is essential
  • 🎯 Final goal is to stabilize pelvic structures

时间轴

  • 00:00:00 - 00:05:00

    The procedure begins with an incision to expose the rectus fascia, aiming to visualize its broad insertion on the anterior and superior aspects of the pubic body. The rectus fascia is carefully dissected to reveal the midline and the crossing of the rectus fibers, ensuring a high proximal split to avoid entering the peritoneal cavity.

  • 00:05:00 - 00:10:00

    The rectus muscle is mobilized away from the pubic body, ensuring that the superior and anterior attachments are released for optimal mobility. Care is taken not to dissect the symphysis ligament while exposing the rectus fascia and maintaining the integrity of the transversalis fascia.

  • 00:10:00 - 00:15:00

    The dissection continues by entering the retropubic space, where adhesions between the bladder and the rectus are carefully broken down to prevent the bladder from being pulled during retraction. This step is crucial for maintaining visibility during the procedure.

  • 00:15:00 - 00:20:00

    The next phase involves dissecting along the superior pubic ramus, where the external iliac vessels and the obturator nerve are identified. Any larger vessels encountered may need to be ligated to facilitate further dissection along the anterior column.

  • 00:20:00 - 00:25:00

    The iliopectineal fascia is released to connect the false pelvis and true pelvis, allowing access to the internal iliac fossa. The iliacus muscle is mobilized to expose the anterior column and facilitate further dissection towards the acetabulum.

  • 00:25:00 - 00:30:00

    As the dissection progresses, the obturator internus muscle is released from the posterior column and quadrilateral surface, ensuring that the obturator nerve is preserved. This step is essential to avoid iatrogenic injury during the procedure.

  • 00:30:00 - 00:36:00

    Finally, the quadrilateral surface and posterior column are fully exposed, allowing for manipulation and fixation of the posterior column. The use of retractors and suction aids in maintaining visibility and access to the surgical site, ensuring a successful outcome.

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思维导图

视频问答

  • What is the main focus of the surgical procedure discussed in the video?

    The main focus is on the dissection and exposure of the rectus fascia and surrounding structures during pelvic surgery.

  • What should be avoided during the dissection?

    Surgeons should avoid damaging the obturator nerve and external iliac vessels.

  • What is the purpose of mobilizing the rectus muscle?

    Mobilizing the rectus muscle allows better access to the pelvic structures for surgical intervention.

  • What is the iliopectineal fascia?

    The iliopectineal fascia is a layer of fascia that needs to be released to connect the false pelvis and true pelvis.

  • How is the obturator nerve managed during the procedure?

    The obturator nerve is mobilized to prevent tension and potential injury during dissection.

  • What is the significance of the quadrilateral surface in this surgery?

    The quadrilateral surface is crucial for accessing and stabilizing the posterior column of the pelvis.

  • What tools are used for stabilization during the surgery?

    Retractors and screws are used for stabilization during the surgical procedure.

  • What is the role of the suction retractor?

    The suction retractor helps push the bladder out of the way and improves visualization during surgery.

  • What is the importance of the iliacus muscle in this procedure?

    The iliacus muscle needs to be mobilized to access the anterior column and quadrilateral surface.

  • What is the final goal of the surgery?

    The final goal is to stabilize the anterior column and quadrilateral surface of the pelvis.

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  • 00:00:08
    so when we make our fan and steel
  • 00:00:10
    incision we're going to come down onto
  • 00:00:14
    the rectus fascia and as we expose the
  • 00:00:18
    rectus fascia we're going to try to come
  • 00:00:22
    as far distantly not just on
  • 00:00:26
    top of the pubic body but we're actually
  • 00:00:30
    going to want to come down over the
  • 00:00:34
    front of the pubic body anteriorly here
  • 00:00:38
    like this so that we see the rectus
  • 00:00:42
    fascia coming down inserting on the
  • 00:00:44
    anterior aspect as well as the superior
  • 00:00:47
    aspect of the pubic bodies you have to
  • 00:00:50
    keep in mind that
  • 00:00:53
    the rectus fascia has a very broad Apon
  • 00:00:57
    neotic sort of insertion on the pubic
  • 00:01:01
    it's not just superiorly it goes all the
  • 00:01:04
    way down the front of the pubic body so
  • 00:01:06
    here's rectus fasha we'll just expose
  • 00:01:09
    that a little bit
  • 00:01:19
    more so here we have the rectus fascia
  • 00:01:23
    exposed anly remember that above the
  • 00:01:27
    umbilicus there is a posterior and an
  • 00:01:30
    anterior rectus fascia but below the
  • 00:01:32
    umus here there's really only an
  • 00:01:34
    anterior rectus fascia on the posterior
  • 00:01:38
    surface of the rectus there's only one
  • 00:01:40
    thin layer of transversalis
  • 00:01:42
    fascia so the midline generally can be
  • 00:01:47
    found by looking for the decoation or
  • 00:01:50
    crossing of the rectus fibers here and
  • 00:01:53
    here and remember we want to come down
  • 00:01:56
    as anterior as we possibly can so here's
  • 00:01:59
    the decoation or crossing of the
  • 00:02:00
    anterior rectus fibers sometimes you can
  • 00:02:03
    actually palpate the linear
  • 00:02:05
    Alba but we're going to come right
  • 00:02:08
    through
  • 00:02:10
    here and it's important to remember that
  • 00:02:14
    we want to try and split the rectus as
  • 00:02:17
    high proximally as we
  • 00:02:21
    can the thing that makes people the most
  • 00:02:24
    nervous about doing this is that they
  • 00:02:26
    inadvertently get into the perial cavity
  • 00:02:29
    if you do get into the peral cavity all
  • 00:02:32
    we have to do from that
  • 00:02:34
    standpoint is take a little bit of
  • 00:02:36
    chromic and just close it up so if we
  • 00:02:40
    look here we can see that the division
  • 00:02:43
    between the two halves so the two heads
  • 00:02:45
    of the rectus is going to be right in
  • 00:02:47
    here we'll come right through there and
  • 00:02:49
    we're going to elevate this portion of
  • 00:02:52
    rectus away from the left side
  • 00:03:00
    and then you'll see that posteriorly
  • 00:03:02
    here we're going to have that one very
  • 00:03:05
    thin layer of transversalis fascia which
  • 00:03:08
    is right here so we've found the
  • 00:03:12
    interval between the right and the left
  • 00:03:15
    half of the rectus gone through the
  • 00:03:16
    linear
  • 00:03:17
    Alba and now we've split our rectus nice
  • 00:03:21
    and high a good at least a good 10 cm up
  • 00:03:25
    from the the pubic
  • 00:03:28
    symphysis and this this fine layer of
  • 00:03:32
    fascia is the transversalis fascia here
  • 00:03:34
    posterior to the rectus and we haven't
  • 00:03:36
    gone through it yet we're just
  • 00:03:38
    mobilizing the right rectus and taking
  • 00:03:40
    it over to the
  • 00:03:41
    contralateral
  • 00:03:43
    side now we're going to relax on this
  • 00:03:46
    retractor and we're going to put it
  • 00:03:50
    distally so that we can see down the
  • 00:03:53
    front of the pubic body now and I'm
  • 00:03:56
    going to take the knife and we're going
  • 00:03:59
    to now release the
  • 00:04:01
    rectus off of the
  • 00:04:04
    superior and then the anterior aspect to
  • 00:04:08
    the pubic bodies here it's important to
  • 00:04:11
    recognize that if we just were to
  • 00:04:14
    release only the superior portion
  • 00:04:17
    attachment right here in the pubic body
  • 00:04:18
    and leave all of this part still
  • 00:04:21
    attached we're not going to be able to
  • 00:04:23
    mobilize the rectus like we want to so
  • 00:04:26
    we're going to come down the front of
  • 00:04:29
    the pubic body like this we're not going
  • 00:04:32
    to dissect or release the symos ligament
  • 00:04:34
    but we are going to take the rectus off
  • 00:04:38
    of the front of the pubic body like this
  • 00:04:42
    so that's a sleeve of rectus right there
  • 00:04:44
    that we're bringing up off of the
  • 00:04:46
    anterior aspect of the pubic body and
  • 00:04:49
    I'm going to keep doing this keep coming
  • 00:04:51
    out laterally
  • 00:04:54
    here like that there's still the rectus
  • 00:04:57
    is still inserted distantly in the pubic
  • 00:04:59
    body and still inserted laterally on the
  • 00:05:01
    pubic body but I'm just taking the more
  • 00:05:03
    medial and
  • 00:05:04
    anterior portion of it off coming this
  • 00:05:08
    way underneath it and we're going to get
  • 00:05:09
    out to the pubic
  • 00:05:13
    tubic you can see that we still have our
  • 00:05:15
    transversalis fascia intact right here
  • 00:05:17
    and we're going to address that in a
  • 00:05:19
    second so as I get to this point here
  • 00:05:22
    you can see that I've taken this whole
  • 00:05:24
    sleeve of rectus and now we're laying it
  • 00:05:27
    over and the final part really is just
  • 00:05:30
    going to be getting out right here right
  • 00:05:33
    to that point right there which is now
  • 00:05:35
    lateral to the pubic
  • 00:05:42
    Tule and this is where we're going to
  • 00:05:44
    put in retractor number one so retractor
  • 00:05:48
    number one remember it goes right in
  • 00:05:51
    that spot right there which is just
  • 00:05:52
    anterior the medial aspect of the
  • 00:05:55
    superior pubic Ramis just lateral to the
  • 00:05:57
    pubic Tule so this retractor number one
  • 00:06:01
    is going to come in here and we're going
  • 00:06:03
    to just slide it just anterior to the
  • 00:06:06
    superior pubic Ramis and then we're
  • 00:06:08
    going to take a
  • 00:06:10
    stabilizing kwire and put it through the
  • 00:06:13
    retractor to hold it in
  • 00:06:21
    place so now we have the distal aspect
  • 00:06:24
    of the rectus out of the way and the
  • 00:06:26
    next part here is going to be coming
  • 00:06:27
    through this fine layer of transversalis
  • 00:06:30
    fascia and a lot of times you can do
  • 00:06:33
    that just by finger dissection and you
  • 00:06:35
    come into the retropubic space of Rus
  • 00:06:37
    here which is between the bladder and
  • 00:06:39
    the posterior aspect of the pubic body
  • 00:06:43
    so here's pubic symphysis
  • 00:06:47
    midline and here is all of that
  • 00:06:50
    transversalis fascia and then we're just
  • 00:06:52
    going to take your finger and we're just
  • 00:06:54
    going to split the transversalis fascia
  • 00:06:56
    approximately like this
  • 00:06:59
    now when you come through that layer of
  • 00:07:01
    transversalis fascia you're going to
  • 00:07:03
    notice that there
  • 00:07:05
    are
  • 00:07:08
    adhesions between the bladder which is
  • 00:07:11
    here and the unders surface of the
  • 00:07:14
    rectus so the first thing you're going
  • 00:07:16
    to do is with finger dissection you're
  • 00:07:17
    just going to sweep your finger on the
  • 00:07:19
    under surface of the
  • 00:07:21
    rectus to break down and get rid of all
  • 00:07:24
    of those little fascial adhesions
  • 00:07:27
    between the bladder and and the rectus
  • 00:07:30
    because as we move the rectus in this
  • 00:07:32
    direction we want the bladder to stay on
  • 00:07:35
    the side of the surgeon not the side of
  • 00:07:37
    the fracture if we if we don't take
  • 00:07:39
    those adhesions down as we retract the
  • 00:07:42
    rectus towards the side of the fracture
  • 00:07:44
    we're going to pull the bladder with it
  • 00:07:46
    and we're not going to be able to
  • 00:07:48
    visualize as well so we need to break
  • 00:07:51
    down those adhesions between bladder and
  • 00:07:53
    under surface of rectus once we got that
  • 00:07:56
    now we can start working along the uh
  • 00:07:59
    Superior pubic Ramis in the anterior
  • 00:08:01
    column well the next phase of this
  • 00:08:04
    operation is going to be dissecting
  • 00:08:06
    along the superior pubic Ramis which is
  • 00:08:10
    right here pubic body and the pubic
  • 00:08:12
    symphysis is right here this is superior
  • 00:08:15
    Ramis here's the pubic
  • 00:08:17
    tubic and the retractor number one is
  • 00:08:19
    just lateral to the pubic tubic come
  • 00:08:22
    along the superior pubic Ramis here all
  • 00:08:25
    right we have the bladder is being
  • 00:08:27
    retracted away from us so it's falling
  • 00:08:29
    away from the anterior column and the
  • 00:08:31
    superior pubic Ramis and in this fascia
  • 00:08:35
    here is where we're going to encounter
  • 00:08:38
    an
  • 00:08:39
    anastomosis between the external iliac
  • 00:08:41
    vessels which are behind this retractor
  • 00:08:44
    and the operator vessels which are down
  • 00:08:46
    here you can just start to see a hint of
  • 00:08:49
    the arbitrator nerve coursing right here
  • 00:08:52
    coming towards the operator Framing and
  • 00:08:55
    exiting there so this vessel that's
  • 00:08:57
    coming down here is coming from from the
  • 00:09:00
    external iliac down over the superior
  • 00:09:02
    Ramis into the operator frame into
  • 00:09:05
    Anastos between the external and the
  • 00:09:06
    internal iliac
  • 00:09:08
    system so depending on the size of this
  • 00:09:11
    vessel it can either be cauterized or
  • 00:09:16
    might need to be ligated if it's a
  • 00:09:18
    little bit larger this one in this case
  • 00:09:20
    is a little bit larger and we' probably
  • 00:09:22
    elect to put a hemoclip or ligate
  • 00:09:25
    instead of just cauterizing it but that
  • 00:09:28
    vessel has to
  • 00:09:30
    be
  • 00:09:32
    ligated Bovi something has to be out of
  • 00:09:35
    the way in order that we can continue
  • 00:09:38
    with the dissection along the superior
  • 00:09:41
    pubic Ramis and the anterior column
  • 00:09:44
    here because the next tissue that we're
  • 00:09:47
    going to encounter is going to be the
  • 00:09:50
    iliopectineal fascia which is this
  • 00:09:53
    reflection of fascia right here coming
  • 00:09:55
    from the superior pubic Ramis up all
  • 00:09:59
    right
  • 00:10:01
    now an important thing to remember
  • 00:10:04
    although people tend to want to try to
  • 00:10:07
    contrast the IL wiell to the anterior
  • 00:10:11
    intrapelvic in
  • 00:10:14
    actuality the surgery is the
  • 00:10:17
    same and the general philosophy is the
  • 00:10:20
    same and that is is that in order to do
  • 00:10:25
    a good anterior approach to the pelvis
  • 00:10:27
    or the acetabulum we need to be able to
  • 00:10:33
    connect the false pelvis which is the
  • 00:10:36
    internal iliac fossa over there
  • 00:10:38
    laterally and the true pelvis down here
  • 00:10:41
    where the bladder is everything below
  • 00:10:43
    the brim so the only way to do that the
  • 00:10:46
    only way to connect those two cavities
  • 00:10:48
    or those two spaces is to release the IL
  • 00:10:52
    optinal fasia which is right here off
  • 00:10:55
    the superior pubic Ramos so in an
  • 00:10:57
    ilioinguinal approach through through
  • 00:11:00
    window number two or the middle
  • 00:11:02
    window we would come through we start
  • 00:11:04
    from the false pelvis we would release
  • 00:11:06
    the IL optinal fascia come down to the
  • 00:11:09
    brim and that would connect us to the
  • 00:11:11
    true pelvis if we're doing an anterior
  • 00:11:14
    intrapelvic approach or an
  • 00:11:16
    AIP we're starting in the true pelvis
  • 00:11:19
    we're going to release the IL optinal
  • 00:11:21
    fascia and that's going to allow us to
  • 00:11:24
    get access up into
  • 00:11:27
    the false pelvis above the brim here we
  • 00:11:31
    can
  • 00:11:31
    see the external iliac vein coming from
  • 00:11:36
    above here above the brim down into the
  • 00:11:39
    pelvis so as we do this we're going to
  • 00:11:42
    place this retractor which can be a dver
  • 00:11:45
    or anything else underneath the external
  • 00:11:47
    iliac vein to protect it and keep it out
  • 00:11:49
    of the way so that we just expose the
  • 00:11:51
    whole pelvic brim for us this is not a
  • 00:11:55
    vein this is the iliacus muscle this
  • 00:11:58
    little purple
  • 00:12:00
    uh bit of tissue right here so first
  • 00:12:03
    order business is going to be to release
  • 00:12:04
    the IL optinal fascia so we're going to
  • 00:12:08
    take our knife and here's the superior
  • 00:12:09
    pubic ramus we're going to come right
  • 00:12:11
    along the brim we're going to run our
  • 00:12:13
    knife right on bone and we're going to
  • 00:12:16
    release that iliopectineal fascia
  • 00:12:19
    underneath that is going to be some
  • 00:12:20
    pectineus
  • 00:12:26
    muscle and we stay right on bone and
  • 00:12:29
    we're safe the whole time the external
  • 00:12:31
    iliac vein is above us the arbitrator
  • 00:12:34
    neurovascular bundle is down well below
  • 00:12:37
    us along the quadrilateral surface so
  • 00:12:39
    there's there are no structures at risk
  • 00:12:41
    here and we have the hip
  • 00:12:45
    flexed so once we've released the fascia
  • 00:12:48
    off of the superior pubic Ramis the IL
  • 00:12:51
    optinal fascia we're going to come with
  • 00:12:53
    an elevator and now this is going to
  • 00:12:55
    allow us to slowly get in underneath
  • 00:12:59
    the ilos soos muscle and tendon over the
  • 00:13:02
    front of
  • 00:13:05
    the superior pubic
  • 00:13:08
    Ramis and you'll recognize that the
  • 00:13:12
    anterior column or the anterior part of
  • 00:13:14
    the pelvic ring is really just a series
  • 00:13:16
    of Hills and Valleys the pubic body is a
  • 00:13:20
    hill and then as you come down lateral
  • 00:13:23
    to the pubic Tule you get into a valley
  • 00:13:25
    which is a superior pubic Ramis as we
  • 00:13:27
    come out farther laterally the pubic
  • 00:13:29
    root is another Hill that we Elevate up
  • 00:13:31
    over top of and then on the other side
  • 00:13:34
    of the pubic root is the so's Gutter and
  • 00:13:37
    we're going to want to get into the so's
  • 00:13:40
    gutter with a retractor so that we
  • 00:13:43
    because we're going to actually want to
  • 00:13:47
    elevate the tissues off of the superior
  • 00:13:49
    pubic Ram so that we can see the
  • 00:13:51
    entirety of the superior pubic Rus out
  • 00:13:53
    to the pubic root like this and then
  • 00:13:57
    eventually over into the se's
  • 00:14:00
    gutter we can't put in retractor number
  • 00:14:02
    two yet until we get out as far as the
  • 00:14:06
    so's gutter in the anterior wall so we
  • 00:14:08
    can take a sharp Homan and just put it
  • 00:14:11
    over the front of the superior pubic
  • 00:14:14
    Ramis so now you can see we have
  • 00:14:17
    Superior pubic Ramis this is the
  • 00:14:19
    beginning or the medial aspect of the
  • 00:14:21
    pubic root right here and then we're
  • 00:14:23
    coming in underneath the iliacus muscle
  • 00:14:26
    here and so as as we come in we're going
  • 00:14:30
    to just stay on bone and stay underneath
  • 00:14:33
    the iliacus
  • 00:14:35
    muscle generally taking it away from its
  • 00:14:38
    origin on the pelvic brim coming in
  • 00:14:41
    underneath it and then that will now
  • 00:14:43
    allow us to get out as far lateral as
  • 00:14:46
    The soas
  • 00:14:47
    Gutter and the base or the beginning of
  • 00:14:50
    the anterior wall of the
  • 00:14:54
    acetabulum up to this point our entire
  • 00:14:57
    dissection is staying above the pelvic
  • 00:15:00
    brim sucal and into the internal iliac
  • 00:15:04
    fossa once we have all of that iliacus
  • 00:15:07
    and ilos soos
  • 00:15:10
    mobilized we can take retractor number
  • 00:15:16
    two and then we're going to run it
  • 00:15:19
    underneath the iliacus and ilos muscle
  • 00:15:22
    tenant out into the so's Gutter and out
  • 00:15:26
    towards the base of the and interior
  • 00:15:29
    wall so we can take this home and out so
  • 00:15:32
    now we can see Superior pubic Ramis
  • 00:15:37
    coming out and we can see all of the
  • 00:15:39
    pubic root here and then now this is
  • 00:15:42
    getting up into the internal iliac fausa
  • 00:15:44
    there while we're still above the pelvic
  • 00:15:49
    brim and in the internal iliac fausa it
  • 00:15:51
    is important that we recognize where the
  • 00:15:55
    arbitrator nerve is and we can take with
  • 00:15:59
    either finger dissection through this
  • 00:16:00
    loose areola and fatty tissue or with a
  • 00:16:04
    pair of Mets and bound scissors
  • 00:16:06
    something but just to mobilize it and
  • 00:16:10
    see where it runs as it runs proximately
  • 00:16:13
    just over the sacr iliac joint up
  • 00:16:16
    towards the lumbo sacral plexus
  • 00:16:19
    because there is still right here you
  • 00:16:22
    can see and now my my uh Mets right now
  • 00:16:26
    are just at the anterior aspect of the S
  • 00:16:28
    really joint and you can see that
  • 00:16:30
    there's still a band of fascia here just
  • 00:16:33
    lateral to the obturator nerve which is
  • 00:16:35
    here so there's this band of fascia
  • 00:16:38
    right here that still is tethering the
  • 00:16:40
    iliacus and the iloo
  • 00:16:43
    muscle so we come in with a BBY or an
  • 00:16:47
    elevator and we just want to release
  • 00:16:49
    that
  • 00:16:51
    fascia so that it's released and we get
  • 00:16:54
    in much more and that will allow us to
  • 00:16:56
    mobilize the iliacus and ilos soos
  • 00:16:59
    muscle much more out of the way and'll
  • 00:17:02
    facilitate getting in retractor number
  • 00:17:04
    three substantially so really you're
  • 00:17:06
    really want to get a good idea of where
  • 00:17:08
    that OB trator nerve is is running is
  • 00:17:10
    running and where it is and and not only
  • 00:17:13
    that but having the obrador nerve
  • 00:17:15
    dissected and mobilizing this is going
  • 00:17:17
    to help us a lot with the second aspect
  • 00:17:20
    or the second half of this exposure
  • 00:17:21
    which is getting down onto the
  • 00:17:23
    quadrilateral surface and the posterior
  • 00:17:25
    column down here so we're going to take
  • 00:17:29
    retractor number three now and we're
  • 00:17:32
    going to put it right here underneath
  • 00:17:35
    the
  • 00:17:36
    iliakis and then we're going to just run
  • 00:17:39
    this up and lateral to the sacroiliac
  • 00:17:42
    joint all right and if you look in there
  • 00:17:45
    you can see where the arbitrator nerve
  • 00:17:47
    is you can see that this retractor is
  • 00:17:50
    just lateral to the cilc joint and
  • 00:17:52
    lateral to where
  • 00:17:56
    the uh arator nerve is running
  • 00:18:00
    now this this retractor here has two
  • 00:18:05
    kwire stabilization points in it one
  • 00:18:08
    that's more medial and one that's more
  • 00:18:10
    lateral we're going to choose to put a
  • 00:18:12
    stabilization pin into the more lateral
  • 00:18:15
    of the two holes so that it will
  • 00:18:21
    stay out of the
  • 00:18:24
    way of our anterior column buttress
  • 00:18:26
    plate when it comes time we only want
  • 00:18:29
    one point of fixation so that we can
  • 00:18:31
    rotate it because we want to keep this
  • 00:18:34
    retractor parallel to the axis that
  • 00:18:39
    the that the uh external iliac vein and
  • 00:18:42
    artery are running in so that they
  • 00:18:46
    don't get tented over the edge of the
  • 00:18:50
    retractor all right so
  • 00:18:53
    now we can see
  • 00:18:57
    the internal the lower part of the
  • 00:19:00
    internal iliac fossa all the way back to
  • 00:19:02
    the SI joint which is right here there's
  • 00:19:06
    OB trator nerve running up just over the
  • 00:19:09
    anterior aspect of the SI joint coming
  • 00:19:11
    down towards the operator
  • 00:19:13
    foramen this is all pelvic brim from SI
  • 00:19:16
    joint pelvic brim pelvic brim coming up
  • 00:19:20
    here Superior pubic Ramis and then
  • 00:19:24
    finally back to pubic body and pubic
  • 00:19:26
    tubal right here so really with this
  • 00:19:29
    exposure so far what we've done just by
  • 00:19:32
    mobilizing the ilos soos and the rectus
  • 00:19:35
    we can see the entire aspect of the
  • 00:19:37
    lower portion of the anterior column as
  • 00:19:39
    well as the internal probably the lower
  • 00:19:41
    half of the internal iliac fosser right
  • 00:19:44
    to the Celiac joint here all right next
  • 00:19:48
    part of this is going to be coming down
  • 00:19:51
    the quadrilateral surface in the postor
  • 00:19:53
    column so again we have our arbitrator
  • 00:19:55
    nerve mobilized and it's important to
  • 00:19:57
    mobilize the OB at nerve because we're
  • 00:20:00
    going to have to eventually work on both
  • 00:20:03
    sides of it up here and down here
  • 00:20:05
    underneath it but the lower we get down
  • 00:20:07
    onto the posterior column we can't
  • 00:20:11
    continue to retract the med operator
  • 00:20:13
    nerve medially so we're going to have to
  • 00:20:15
    start working below it down
  • 00:20:17
    here all
  • 00:20:19
    right so by way of
  • 00:20:22
    orientation looking at the quad upper
  • 00:20:24
    portion of the quadrilateral surface in
  • 00:20:26
    the posterior column this is the OB
  • 00:20:28
    internis muscle and a lot of times in
  • 00:20:31
    the fracture scenario this muscle is
  • 00:20:33
    already going to be disrupted and torn
  • 00:20:36
    some cases it's not and you have to
  • 00:20:38
    release its fascia away from the pelvic
  • 00:20:41
    brim here so that we can start to
  • 00:20:43
    release it and mobilize it away from the
  • 00:20:46
    posterior column and the operator or the
  • 00:20:49
    posterior column and the quadrilateral
  • 00:20:50
    surface so we're going to start above
  • 00:20:52
    the nerve here and we're just going to
  • 00:20:54
    start releasing and
  • 00:20:56
    mobilizing the obit trator internis
  • 00:20:59
    muscle now you can start to see here
  • 00:21:01
    below the brim you can start to see the
  • 00:21:05
    bone and the surface of the posterior
  • 00:21:07
    column and the quadrilateral surface so
  • 00:21:10
    we're just going to keep releasing and
  • 00:21:13
    sometimes this muscle is disrupted or
  • 00:21:16
    badly damaged and if that's the case you
  • 00:21:18
    can take some of it out debride some of
  • 00:21:20
    it with a round jure but now as I'm
  • 00:21:23
    coming further down the quadrilateral
  • 00:21:25
    surface and the posterior CM I'm going
  • 00:21:27
    to come in here underneath
  • 00:21:29
    the arbitrator nerve and
  • 00:21:33
    continue to mobilize the arbitrator
  • 00:21:35
    internis muscle and this way I'm not
  • 00:21:38
    putting any
  • 00:21:40
    tension on the obit terator nerve and
  • 00:21:43
    avoiding the
  • 00:21:45
    weariness of the obturator nerve that
  • 00:21:48
    some people
  • 00:21:49
    are can be concerned about which is
  • 00:21:53
    clearly an issue we don't want to cause
  • 00:21:55
    any iatrogenic injury to the obit
  • 00:21:58
    terator nerve a point uh of
  • 00:22:02
    consideration here during this
  • 00:22:03
    dissection and and another uh endorsment
  • 00:22:06
    of lateral femal traction is that with a
  • 00:22:09
    lot of these fractures where there's a
  • 00:22:11
    lot of displacement of the quadrilateral
  • 00:22:13
    surface and the posterior column into
  • 00:22:16
    the pelvis because of the femoral head
  • 00:22:18
    what that does is it puts a lot of
  • 00:22:20
    tension on the opor nerve and an obit
  • 00:22:23
    trator nerve here will be will be tented
  • 00:22:27
    or stretched
  • 00:22:29
    over that fracture fragment of the
  • 00:22:32
    quadral surface in the posterior column
  • 00:22:34
    it'll be in like this so getting the
  • 00:22:36
    femal head out and with ligamentotaxis
  • 00:22:39
    or capsula taxis pulling that quadral
  • 00:22:43
    surface in the in the postor column back
  • 00:22:45
    laterally it takes tension off of the
  • 00:22:47
    operator nerve and it makes the
  • 00:22:49
    dissection actually quite a bit
  • 00:22:52
    easier so I'm going to continue to just
  • 00:22:55
    peel OB trator and turnus off of the
  • 00:22:59
    posterior column here in this situation
  • 00:23:02
    since this is a cadaver and it's not
  • 00:23:03
    fractured you can see right here the
  • 00:23:06
    obor vein is still intact as is the
  • 00:23:08
    artery that runs with it and in the
  • 00:23:11
    fracture scenario that's
  • 00:23:14
    often torn so as we continue to take off
  • 00:23:19
    the operator internis muscle from the
  • 00:23:22
    posterior column and quadrilateral
  • 00:23:24
    surface we'll get to a point where we
  • 00:23:27
    come into the greater sciatic Notch
  • 00:23:29
    which is right here so the cob is coming
  • 00:23:33
    down posterior column and now it's into
  • 00:23:35
    the greater sciatic Notch here and you
  • 00:23:36
    can see I'm working below the arbitrator
  • 00:23:39
    nerve so as we do this we have to keep
  • 00:23:44
    in mind that to facilitate this
  • 00:23:46
    reduction what we've done is we've
  • 00:23:49
    flexed the hip so that we can relax the
  • 00:23:53
    ILO soos but by doing that we put a
  • 00:23:57
    little bit more tension
  • 00:23:58
    onto the sciatic nerve just like we
  • 00:24:01
    would if we were doing an ilioinguinal
  • 00:24:03
    so anytime we do any dissection down
  • 00:24:06
    here along the posterior border of the
  • 00:24:09
    medial surface of the posterior column
  • 00:24:11
    which is right here we have to be
  • 00:24:13
    careful as we come into the greater not
  • 00:24:15
    so we don't do any plunging because
  • 00:24:17
    that's going to put some pressure onto
  • 00:24:19
    the stic nerve and potentially injure
  • 00:24:21
    the stic nerve so keep in mind that the
  • 00:24:23
    satic nerve even though this is an
  • 00:24:24
    anterior exposure that the satic nerve
  • 00:24:27
    is something that in our operative field
  • 00:24:29
    but this cob here is now on
  • 00:24:32
    the posterior border of the posterior
  • 00:24:34
    column right in the greater sciatic
  • 00:24:36
    Notch now and this dissection will be
  • 00:24:38
    carried down dist in this fashion all
  • 00:24:41
    the way here onto the iscal spine and
  • 00:24:45
    this cob right here this tissue here is
  • 00:24:49
    the iscal spine and the distal insertion
  • 00:24:52
    of the sacrospinous ligament right there
  • 00:24:54
    so this is all from here to here this is
  • 00:24:57
    all greater static frame in a greater
  • 00:24:59
    Notch coming down and then onto iscal
  • 00:25:02
    spine right there so we have essentially
  • 00:25:06
    the entire medial surface of the
  • 00:25:08
    posterior column from the lateral to the
  • 00:25:11
    sac joint the pelvic brim the whole
  • 00:25:14
    surface of the posterior column all the
  • 00:25:16
    way down to the iscal spine exposed as
  • 00:25:20
    well as the quadrilateral surface which
  • 00:25:23
    is right in this whole area right here
  • 00:25:26
    it's all quadrilateral surface so we
  • 00:25:29
    have that whole bit of of acetum now
  • 00:25:32
    exposed so we can control manipulate and
  • 00:25:35
    even fixate the posterior column from
  • 00:25:38
    its medial aspect here have access to
  • 00:25:41
    the quadrilateral
  • 00:25:44
    surface pelvic brim from the SI joint
  • 00:25:48
    all the way to the pubic body and the
  • 00:25:51
    lower half of the internal iliac fausa
  • 00:25:55
    and here along the anterior column over
  • 00:25:57
    the pubic root and this is so's gutter
  • 00:26:00
    right here so we have all this exposure
  • 00:26:04
    through this anterior inter pelvic
  • 00:26:07
    window right here the final retractor
  • 00:26:11
    the suction
  • 00:26:13
    retractor is used at the base of the
  • 00:26:16
    wound once we finally dissected along
  • 00:26:18
    the quadral surface and into the
  • 00:26:20
    posterior column and greater static
  • 00:26:22
    framing so this portion the blunt
  • 00:26:25
    portion of this retractor is going to be
  • 00:26:26
    placed right onto either the posterior
  • 00:26:30
    column or into the greater sciatic Notch
  • 00:26:33
    carefully so
  • 00:26:36
    that the bladder can be pushed out of
  • 00:26:40
    the way like this and so this retractor
  • 00:26:44
    is going to help to it's going to come
  • 00:26:46
    in underneath the obturator nerve which
  • 00:26:48
    is right here remember it's medial to
  • 00:26:51
    the nerve so the nerves not being
  • 00:26:52
    retracted with the suction
  • 00:26:54
    retractor the tip of the retractor goes
  • 00:26:56
    into just the beginning part part of the
  • 00:26:58
    greater satic framan and levers on that
  • 00:27:01
    posterior aspect of the posterior column
  • 00:27:03
    and then this portion of the retractor
  • 00:27:05
    here is pushing the bladder out of the
  • 00:27:07
    way so that it improves our
  • 00:27:09
    visualization down here into the pelvis
  • 00:27:12
    so now we see that whole pelvic brim we
  • 00:27:13
    see the quadrilateral surface and we see
  • 00:27:15
    the posterior column and then here's the
  • 00:27:18
    iscal
  • 00:27:19
    spine all right at the same time the
  • 00:27:23
    suction is evacuating any of the fluids
  • 00:27:25
    that are corre collecting down here at
  • 00:27:27
    the base of the
  • 00:27:33
    wound this is the Sprite screw inserter
  • 00:27:36
    we'll just demonstrate the use of it and
  • 00:27:39
    sometimes uh what we'll we'll assume
  • 00:27:41
    that we have our reduction clamps in
  • 00:27:43
    place and now we're putting in screws
  • 00:27:47
    to replace reduction clamps with either
  • 00:27:50
    position screws or lag
  • 00:27:53
    screws canula for the drill is in place
  • 00:28:01
    the calibrated drill bit comes in and
  • 00:28:03
    we're going to drill from the brim out
  • 00:28:05
    towards the suas toab our bone
  • 00:28:08
    posteriorly in this
  • 00:28:10
    situation and when I feel that we've
  • 00:28:12
    come to that far
  • 00:28:17
    CeX we're going to measure the depth off
  • 00:28:19
    the calibration with the
  • 00:28:22
    sleeve then the
  • 00:28:25
    drill the inner canula would be be
  • 00:28:30
    removed and then we will take a
  • 00:28:34
    screw and place it
  • 00:28:37
    in and then we'll follow with
  • 00:28:41
    the screw
  • 00:28:47
    driver until the screw is seated
  • 00:28:59
    it's important to remember where the
  • 00:29:01
    arbitrator nerve is and
  • 00:29:04
    where the retractor number three is
  • 00:29:06
    remember that this this plate is going
  • 00:29:11
    to come to
  • 00:29:13
    lie lateral to the obturator nerve and
  • 00:29:17
    you can see where it's sitting now just
  • 00:29:20
    lateral to the sck reallya Joint
  • 00:29:23
    proximally up here it has to be medial
  • 00:29:28
    to the stabilization pin in retractor
  • 00:29:30
    number three here so that's why we try
  • 00:29:32
    to use the more lateral of the two pin
  • 00:29:34
    slots so that our anterior column
  • 00:29:37
    buttress plate can come up and lay down
  • 00:29:39
    nicely just lateral to the Celiac joint
  • 00:29:42
    which is right here that's the sac joint
  • 00:29:45
    there's our obturator nerve so our plate
  • 00:29:47
    has come in along the quadrilateral
  • 00:29:50
    surface just lateral to the obturator
  • 00:29:53
    nerve
  • 00:29:54
    now like we've discussed in the past the
  • 00:29:58
    this is a buttress
  • 00:29:59
    plate that has to buttress both the
  • 00:30:02
    anterior column and the quadrilateral
  • 00:30:05
    surface the plate itself is not a
  • 00:30:07
    reduction tool we should have the
  • 00:30:09
    posterior column the anterior column
  • 00:30:11
    everything reduced before replacing our
  • 00:30:14
    neutralization plate
  • 00:30:15
    here now in order to ensure that this
  • 00:30:19
    plate is going to be snug up against the
  • 00:30:23
    quadrilateral surface to to provide a
  • 00:30:24
    good buttress to the quadrilateral
  • 00:30:26
    surface in the posterior column
  • 00:30:28
    as well as being down for the anterior
  • 00:30:31
    column
  • 00:30:32
    portion the easiest way to accomplish
  • 00:30:35
    that is we're going to use the handle
  • 00:30:37
    for the plate
  • 00:30:39
    insertion to lateralize the plate and
  • 00:30:42
    push against the quadr lateral
  • 00:30:45
    surface then what we're going to do is
  • 00:30:49
    we're going to follow with a screw in
  • 00:30:51
    the plate right around the posterior arm
  • 00:30:54
    here so into this
  • 00:30:56
    hole or the one just posterior to it but
  • 00:31:00
    we're going to drill that screw as
  • 00:31:02
    eccentrically as possible and the
  • 00:31:04
    lateral side of the hole so that as the
  • 00:31:07
    plate is pushed down onto the bone by
  • 00:31:11
    the screw head in the supercanal region
  • 00:31:14
    it also continues to lateralize and want
  • 00:31:16
    to push the plate more lateral so again
  • 00:31:20
    that first screw that comes in is going
  • 00:31:22
    to be this screw back here by the
  • 00:31:25
    posterior arm drilled in an eent Centric
  • 00:31:28
    fashion to pull the plate laterally as
  • 00:31:30
    it brings it down onto the anterior
  • 00:31:34
    column or the supercanal
  • 00:31:38
    bone by lateralizing and pushing the
  • 00:31:41
    plate against the posterior column and
  • 00:31:43
    quadrilateral surface we're going to
  • 00:31:46
    drill
  • 00:31:51
    eccentrically and once the plate is down
  • 00:31:54
    and secured in position
  • 00:31:58
    the plate insertion handle can be
  • 00:32:04
    removed check to ensure that the
  • 00:32:06
    operator nerve is hanging
  • 00:32:09
    freely and
  • 00:32:11
    then we can take another reduction Force
  • 00:32:14
    up I'm going to put this reduction Force
  • 00:32:17
    up on the anterior aspect of the plate
  • 00:32:21
    to bring it down onto the pubic body
  • 00:32:25
    next we'll come back and re verify that
  • 00:32:28
    the plate is flush on both the anterior
  • 00:32:33
    column and the quadrilateral surface as
  • 00:32:37
    well as posterior column right
  • 00:32:40
    there we'll continue on with securing
  • 00:32:44
    the quadrilateral surface portion of the
  • 00:32:46
    plate or into the posterior
  • 00:32:51
    column with screws into the posterior
  • 00:32:54
    column just posterior to the acet Tulum
  • 00:32:59
    in this particular plate there are three
  • 00:33:01
    holes in the posterior limb one just
  • 00:33:05
    above the iscal
  • 00:33:09
    spine one Midway and a third final one
  • 00:33:13
    that's up here just above the greater
  • 00:33:16
    sciatic
  • 00:33:19
    Notch at the level of the stic buttress
  • 00:33:23
    depending on the fracture pattern and
  • 00:33:25
    the location of the fracture line the
  • 00:33:27
    surgent has to choose which one of these
  • 00:33:31
    screw holes and screw positions is going
  • 00:33:33
    to be optimal in this
  • 00:33:36
    situation we'll put a screw into the
  • 00:33:38
    middle hole of the plate directed into
  • 00:33:41
    the posterior
  • 00:33:51
    column we'll measure it again with the
  • 00:33:54
    calibration
  • 00:33:58
    and that's about a 28 so a 30 will be
  • 00:34:08
    fine we'll put the screw into the handle
  • 00:34:11
    of the plate screw
  • 00:34:13
    inserter and insert the screw and
  • 00:34:22
    driver and then remember with the plate
  • 00:34:25
    screw inserter as the yellow line line
  • 00:34:28
    on the screwdriver approaches the handle
  • 00:34:31
    we have to then bring the handle back
  • 00:34:33
    slightly so that the screw head does not
  • 00:34:36
    capture the
  • 00:34:37
    sleeve in the screw hole of the
  • 00:34:43
    plate we then back it up all the way
  • 00:34:46
    verify the screw position and we can see
  • 00:34:49
    that the screw is now in the posterior
  • 00:34:51
    column of the
  • 00:34:56
    plate so this screw is now behind the
  • 00:34:58
    acetabulum or posterior to the
  • 00:35:00
    acetabulum which is over here directed
  • 00:35:03
    in the posterior column of the plate
  • 00:35:06
    posterior to the
  • 00:35:08
    acetabulum so you'll then follow with
  • 00:35:11
    another screw closer to the curc Joint
  • 00:35:14
    the most posterior aspect of the plate
  • 00:35:17
    and then gradually work your way along
  • 00:35:20
    the anterior column with screw fixation
  • 00:35:23
    into the pubic body and the superior
  • 00:35:25
    pubic
  • 00:35:26
    Ramis for
标签
  • surgery
  • pelvic surgery
  • rectus fascia
  • obturator nerve
  • iliopectineal fascia
  • quadrilateral surface
  • posterior column
  • surgical dissection
  • stabilization
  • retractors