This document describes the surgical procedure for repairing a symphysis pubis separation. The key steps involve: 1) Making an incision above the pubic symphysis and retracting tissues to expose the injury; 2) Splitting the rectus muscles and using retractors to further expose the pubic bones; 3) Reducing the separated pubic bones using a clamp; 4) Placing a contoured metal plate and screws to stabilize the repaired symphysis.

2. AP X-RAY DEMONSTRATING APC TYPE 2
SYMPHYSEAL SEPARATION

3. INLET VIEW DEMONSTRATING
SEPARATION OF THE SYMPHYSIS

4. OUTLET VIEW

5. The patient is prepped, such that the symphysis
is exposed inferiorly, the umbilicus superiorly and
the ASIS laterally.

6. The incision begins two finger breadths
above the symphysis pubis.

7. The incision begins two finger breadths
above the symphysis pubis.

8. RECTUS MUSCLE
Frequently, one of the rectus heads is avulsed from
one of the symphyseal bodies. Occasionally there is
a split in the rectus fascia.

9. Gelpi retractors are placed at the wound edges to
help identify Scarpa’s fascia and then the external
oblique and rectus fascia.

10. The soft tissue is elevated superiorly and inferiorly
from the external oblique and rectus fascia with
the knife held essentially parallel with the body.
EXTERNAL
OBLIQUE
FASCIA

11. The soft tissue is elevated superiorly and inferiorly
from the external oblique and rectus fascia with
the knife held essentially parallel with the body.

12. HEAD
FOOT
The linea alba is easily identified by observing the
confluence of the fibers of the external oblique in the
midline.

13. HEAD
FOOT
The dotted line is placed on the linea alba; the
fascia between the two rectus muscles is divided
sharply but only through the fascia.

14. HEAD
FOOT
RECTUS MUSCLE
Blunt dissection between the rectus muscle is performed,
allowing protection of the peritoneum proximally, and bladder
and bladder neck distally.

15. HEAD
FOOT
The rectus is then divided with
a Bovi on top of the digit.
RECTUS MUSCLE

16. BLADDER
HEAD FOOT
Once the rectus is split, a blunt retractor can be placed,
eventually holding back the bladder. In this figure, the
bladder region is visualized just proximal to the
symphyseal region underneath the rectus.

17. RECTUS
FOOT
By lifting the rectus superiorly with the finger, a
Hohmann retractor can be placed through the
periosteum at the superior and proximal edge of
the superior ramus just lateral to the symphyseal
body.
HEAD

18. RECTUS
HEAD FOOT
This is used to retract the rectus laterally.

19. With the rectus being held laterally, a bovi can be
used to clean the superior surface of the superior
ramus in the area in which the plate will be placed.
SUPERIOR
RAMUS
FOOT
HEAD

20. SYMPHYSEAL
RECTUS BODY
With the legs held together and the retractors in place,
the symphyseal separation is already partly reduced.
The sucker is within the symphyseal separation.
FOOT
HEAD

21. FOOT
HEAD
RECTUS
The Weber clamp is used to reduce the symphysis. It should be
placed superficial and distal to the rectus insertion rather than
dissecting the rectus subperiosteally from the front of the pelvis.

22. FOOT
HEAD
RECTUS
In 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.

23. REDUCTION
After the clamp is engaged, the symphysis is reduced
using the clamp. The clamp must be leaned towards
the feet in order to fully engage the tongs.

24. DEMONSTRATION OF THE
REDUCED SYMPHYSIS PUBIS
FOOT
HEAD

25. If a standard 6-hole curved plate is used, a downward bend is
essential at the outer aspect of the plate as the middle
two screws on each side go into the symphyseal body while
the last screw goes into the ramus, lateral to
the pubic tubercle.

26. The plate is also contoured in order to fit the bend of the
pelvis, which in men is usually an increased bend and in
women, a slight opening of the plate.

27. DRILLING
ECCENTRICALLY
The 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.

28. DRILLED
ECCENTRICALLY
RAMUS
The first screw that is placed is left somewhat proud
so as not to pull the plate over while the second screw
is placed in a similar fashion eccentrically in the hole.

29. The two screws are then tightened together,
allowing compression of the symphysis.

30. Anatomic reduction of the symphysis is achieved
and all the screw holes are filled.

31. RECTUS
HEAD FOOT
After 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.

32. EDGE OF
RECTUS FASCIA
It is important not to tie through the entire rectus muscle,
as this may cause necrosis of part of that muscle.

33. COMPLETE
REPAIR
HEAD FOOT
HEMOVAC
DRAIN
Completed running closure of the rectus fascia, with the
Hemovac drain emerging from within the rectus muscle.

34. AP POSTOPERATIVE VIEW

35. INLET VIEW

36. OUTLET VIEW