a new easier pararectus approach to the anterior acetabulum that is extensile, few windows, and no damage to the rectus

1. An Anterior Acetabular
Approach
Duane Anderson, MD
June 2019

2. Dedicated to Dr Pierre Guy and Dr Thomas Higgins
• Associate Professor of Trauma at
University of BC, Vancouver
• He gave a lecture at the OTA in
2012 and gave me his talk on the
Stoppa Approach
• The next slide is his slide from that
talk
• Dr Thomas Higgins, Professor of
Trauma, U of Utah
• showed me the Stoppa at the U of
Utah

3. The Stoppa by Dr. Pierre Guy
• NV structures are pulled laterally
to expose the superior
acetabulum.
• However the trajectory of the
drill is limited by the retraction
of the ipsilateral rectus.
• This is the main disadvantage of
the Stoppa

4. An Epiphany
• I was helping an obstetrician with a C-section here in Ethiopia years ago
• I thought the Fannenstiel skin incision could be useful for pelvis and
acetabulum if it was deepened and was extensile
• I was not really happy with the Stoppa and ilioinguinal approach for
several reasons
• The Stoppa wouldn’t allow you to look down on the acetabulum, my back
hurt… working across from the patient…., injured the recti
• The ilioinguinal was cumbersome moving around the vessels, it made me
nervous, it has limited visualization of the posterior part of the
acetabulum…

5. Ideal anterior acetabular approach
• Extensile
• Direct vision
• Work on either side of the table
• Exposure from SI joint to the pubis
• See the dome, anterior wall, quadrilateral wall, pubis, and SI joint
through the same incision
• Plate superiorly or medially per surgeon’s choice
• Avoid moving vessels around
• You don’t need a general surgeon holding your hand….

6. So, with God’s help I forged ahead…..
• Transverse incision that is extensile to be able to plate the opposite
side of the pubis if needed
• Avoid injury to the rectus abdominus by avoiding retraction of that
muscle
• Avoid playing around with the vessels as much as possible
• Working on the ipsilateral side and contralateral side of the table for
maximum options of trajectory of the drill and other instruments
• Plating superiorly on the dome, and medially on the brim without
difficulty
• Exposure from the SI joint to the Pubis through the same incision…

7. Extensile, able to plate both sides
distal
proximal
rightleft

8. No injury to the recti

9. Medial and superior plate, direct vision… no
playing around with vessels
vessels
proximal
distal
recti
Right

10. left hip, pubis to SI
Spermatic
cord
Quad
plate
Ant wall
distal
proximal
right

11. Good drill trajectory from the ipsilateral side

12. setup
• Supine on regular or Radiolucent
table
• Triangle under the ipsilateral
femur to relax the psoas
• Traction on the femur or tibia
over traction set up
• Foley
• Prep the lower abdomen and
ipsilateral hip for possible lateral
traction

13. Fannenstiel (transverse) skin incision
moved slightly towards the operative side.

14. After the skin is the anterior rectus sheath
and the external oblique

15. Internal oblique 2nd layer of the lateral
abdominal wall

16. 3rd layer, Arcuate line
Arcuate line is the
lower edge of the
posterior leaf of
the rectus sheath
3rd layer of
the lateral
wall

17. Abdominal wall anatomy
We incise
below the
arcuate
line so
there is
NO
posterior
rectal
fascia

18. Upper and lower abdominal wall difference
there is no posterior rectal sheath….
So this is the wrong
diagram, this is
upper abdomen
This is where
we work
Posterior
rectus
sheath
No
posterior
rectus
sheath

19. Fascial incision is the same as the skin incision
Do NOT cut the recti!
Just cut white tissue at the beginning

20. Fascial incision is the same as the skin incision
Do NOT cut the recti!
t the beginningjust
Just cut the white
tissue at the
beginning

21. Mobilize by dissection the anterior rectus sheath
proximal and distal with the attached 3 layers of the
abdominal wall

22. Mobilize by dissection the anterior rectus sheath
proximal and distal with the attached 3 layers of the
abdominal wall

23. Mobilize by dissection the anterior rectus sheath
proximal and distal with the attached 3 layers of the
abdominal wall

24. This is where care is needed to avoid entering the peritoneal cavity

25. Cut carefully completely through the lateral 3
layers of the abdominal wall staying out of the
peritoneum in line with the skin incision
rectus
Lateral layers
peritoneum
Left Side
Left side

26. Too deep, put it back and sew the peritoneum
Right side

27. Peritoneum repaired with running stitch

28. Finger dissect between the peritoneum and the
abdominal wall to the pelvic brim and the external
iliac vessels
• Vessels are immediately
adjacent to the iliopsoas
• The vessels are pulled and
retracted laterally like the
Stoppa
• The pelvic brim is exposed
• Displaced fractures can be felt
immediately adjacent to the
vessels
• Dissect along the pelvic brim
psoas

29. Inferior epigastric vessels
left Right Right
Distal
Distal
vein
artery
Spermatic
cord
Epigastric VV

30. Right side
Ex Il Artery
Ext Il vein
Peritoneum
Inferior Ep Art
and Vein
Spermatic
cord
Obturator
nerve
Inf epi art
Spermatic
cord
proximal

31. Ligated Inferior epigastric vessels, in the
female you can ligate the round ligament
Inf ep vein
Spermatic
cord

32. Close fascial layer in running suture

33. Close fascial layer in running suture

34. Close fascial layer in running suture

35. 5 cases

36. Preop young female

37. postop

38. post-op

39. One incision

40. Preop young male

41. 17 months

42. 17 months

43. Young woman

44. 13 month fu

45. Crazy woman, you don’t have those…..

46. 2 month follow-up, no crutches, no limp

47. Pre-op

49. post-op

50. Post-op

51. Complications that I recall
• I have been doing this approach for at least five years now, we are
planning on compiling the cases for follow-up
• 1 death early on, intra-operative blood loss that lead to shock,
transfused intra-op, waited an hour and finished the case, went into
shock during the night and died
• 2 vein injuries repaired, slipped or misplaced retractors
• No hernias, no infections that I know of