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1、AP X-RAY DEMONSTRATING APC TYPE 2SYMPHYSEAL SEPARATIONINLET VIEW DEMONSTRATING SEPARATION OF THE SYMPHYSISOUTLET VIEWThe patient is prepped,such that the symphysis is exposed inferiorly,the umbilicus superiorly and the ASIS laterally.The incision begins two finger breadths above the symphysis pubis.
2、The incision begins two finger breadths above the symphysis pubis.Frequently,one of the rectus heads is avulsed from one of the symphyseal bodies.Occasionally there is a split in the rectus fascia.RECTUS MUSCLEGelpi retractors are placed at the wound edges to help identify Scarpas fascia and then th
3、e external oblique and rectus fascia.The soft tissue is elevated superiorly and inferiorlyfrom the external oblique and rectus fascia withthe knife held essentially parallel with the body.EXTERNALOBLIQUEFASCIAThe soft tissue is elevated superiorly and inferiorlyfrom the external oblique and rectus f
4、ascia withthe knife held essentially parallel with the body.The linea alba is easily identified by observing the confluence of the fibers of the external oblique in the midline.FOOTHEADThe dotted line is placed on the linea alba;the fascia between the two rectus muscles is dividedsharply but only th
5、rough the fascia.HEADFOOTFOOTBlunt dissection between the rectus muscle is performed,allowing protection of the peritoneum proximally,and bladder and bladder neck distally.RECTUS MUSCLEHEADHEADFOOTThe rectus is then divided with a Bovi on top of the digit.RECTUS MUSCLEHEADFOOTBLADDEROnce the rectus
6、is split,a blunt retractor can be placed,eventually holding back the bladder.In this figure,thebladder region is visualized just proximal to the symphyseal region underneath the rectus.FOOTRECTUSBy lifting the rectus superiorly with the finger,a Hohmann retractor can be placed through the periosteum
7、 at the superior and proximal edge of the superior ramus just lateral to the symphyseal body.HEADFOOTHEADRECTUSThis is used to retract the rectus laterally.With the rectus being held laterally,a bovi can beused to clean the superior surface of the superiorramus in the area in which the plate will be
8、 placed.SUPERIORRAMUSFOOTHEADSYMPHYSEALBODYRECTUSWith the legs held together and the retractors in place,the symphyseal separation is already partly reduced.The sucker is within the symphyseal separation.FOOTHEADFOOTHEADRECTUSThe Weber clamp is used to reduce the symphysis.It should be placed superf
9、icial and distal to the rectus insertion rather than dissecting the rectus subperiosteally from the front of the pelvis.FOOTHEADRECTUSIn 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.Aft
10、er the clamp is engaged,the symphysis is reducedusing the clamp.The clamp must be leaned towardsthe feet in order to fully engage the tongs.REDUCTIONDEMONSTRATION OF THE REDUCED SYMPHYSIS PUBISFOOTHEADIf a standard 6-hole curved plate is used,a downward bend isessential at the outer aspect of the pl
11、ate as the middletwo screws on each side go into the symphyseal body whilethe last screw goes into the ramus,lateral to the pubic tubercle.The plate is also contoured in order to fit the bend of thepelvis,which in men is usually an increased bend and inwomen,a slight opening of the plate.DRILLINGECC
12、ENTRICALLYThe 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.The first screw that is placed is left somewhat proudso
13、as not to pull the plate over while the second screwis placed in a similar fashion eccentrically in the hole.DRILLEDECCENTRICALLYRAMUSThe two screws are then tightened together,allowing compression of the symphysis.Anatomic reduction of the symphysis is achievedand all the screw holes are filled.REC
14、TUSAfter 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.FOOTHEADEDGE OFRECTUS FASCIAIt is important not to tie through the entire rectus muscle,as this may cause necrosis of part of that muscle.Completed running closure of the rectus fascia,with theHemovac drain emerging from within the rectus muscle.HEADFOOTCOMPLETE REPAIRHEMOVACDRAINAP POSTOPERATIVE VIEWINLET VIEWOUTLET VIEW