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APX-RAYDEMONSTRATINGAPCTYPE2SYMPHYSEALSEPARATION
1INLETVIEWDEMONSTRATINGSEPARATIONOFTHESYMPHYSIS
2OUTLETVIEW
3Thepatientisprepped,suchthatthesymphysisisexposedinferiorly,theumbilicussuperiorlyandtheASISlaterally.
4Theincisionbeginstwofingerbreadthsabovethesymphysispubis.
5Theincisionbeginstwofingerbreadthsabovethesymphysispubis.
6Frequently,oneoftherectusheadsisavulsedfromoneofthesymphysealbodies.Occasionallythereisasplitintherectusfascia.RECTUSMUSCLE
7GelpiretractorsareplacedatthewoundedgestohelpidentifyScarpa’sfasciaandthentheexternalobliqueandrectusfascia.
8Thesofttissueiselevatedsuperiorlyandinferiorlyfromtheexternalobliqueandrectusfasciawiththeknifeheldessentiallyparallelwiththebody.EXTERNALOBLIQUEFASCIA
9Thesofttissueiselevatedsuperiorlyandinferiorlyfromtheexternalobliqueandrectusfasciawiththeknifeheldessentiallyparallelwiththebody.
10Thelineaalbaiseasilyidentifiedbyobservingtheconfluenceofthefibersoftheexternalobliqueinthemidline.FOOTHEAD
11Thedottedlineisplacedonthelineaalba;thefasciabetweenthetworectusmusclesisdividedsharplybutonlythroughthefascia.HEADFOOT
12FOOTBluntdissectionbetweentherectusmuscleisperformed,allowingprotectionoftheperitoneumproximally,andbladderandbladderneckdistally.RECTUSMUSCLEHEAD
13HEADFOOTTherectusisthendividedwithaBoviontopofthedigit.RECTUSMUSCLE
14HEADFOOTBLADDEROncetherectusissplit,abluntretractorcanbeplaced,eventuallyholdingbackthebladder.Inthisfigure,thebladderregionisvisualizedjustproximaltothesymphysealregionunderneaththerectus.
15FOOTRECTUSByliftingtherectussuperiorlywiththefinger,aHohmannretractorcanbeplacedthroughtheperiosteumatthesuperiorandproximaledgeofthesuperiorramusjustlateraltothesymphysealbody.HEAD
16FOOTHEADRECTUSThisisusedtoretracttherectuslaterally.
17Withtherectusbeingheldlaterally,abovicanbeusedtocleanthesuperiorsurfaceofthesuperiorramusintheareainwhichtheplatewillbeplaced.SUPERIORRAMUSFOOTHEAD
18SYMPHYSEALBODYRECTUSWiththelegsheldtogetherandtheretractorsinplace,thesymphysealseparationisalreadypartlyreduced.Thesuckeriswithinthesymphysealseparation.FOOTHEAD
19FOOTHEADRECTUSTheWeberclampisusedtoreducethesymphysis.Itshouldbeplacedsuperficialanddistaltotherectusinsertionratherthandissectingtherectussubperiosteallyfromthefrontofthepelvis.
20FOOTHEADRECTUSInthefigure,therectusmusclesareallowedtofallbacktotheirneutralpositionsothattheclampcanbepushedthroughthesuperficialtissuesdistaltothem.
21Aftertheclampisengaged,thesymphysisisreducedusingtheclamp.Theclampmustbeleanedtowardsthefeetinordertofullyengagethetongs.REDUCTION
22DEMONSTRATIONOFTHEREDUCEDSYMPHYSISPUBISFOOTHEAD
23Ifastandard6-holecurvedplateisused,adownwardbendisessentialattheouteraspectoftheplateasthemiddletwoscrewsoneachsidegointothesymphysealbodywhilethelastscrewgoesintotheramus,lateraltothepubictubercle.
24Theplateisalsocontouredinordertofitthebendofthepelvis,whichinmenisusuallyanincreasedbendandinwomen,aslightopeningoftheplate.
25DRILLINGECCENTRICALLYThescrewsimmediatelyadjacenttothesymphysisareplacedanglingslightlyawayfromthesymphysis,parallelingtheposterioraspectofthesymphysealbodyandeccentricallywithintheplatescrewholestoallowforsomecompression.
26Thefirstscrewthatisplacedisleftsomewhatproudsoasnottopulltheplateoverwhilethesecondscrewisplacedinasimilarfashioneccentricallyinthehole.DRILLEDECCENTRICALLYRAMUS
27Thetwoscrewsarethentightenedtogether,allowingcompressionofthesymphysis.
28Anatomicreductionofthesymphysisisachievedandallthescrewholesarefilled.
29RECTUSAfterfixation,aHemovacdrainshouldbeplacedinthespaceofRetzius,asdemonstratedhere.Oncethewoundisthoroughlyirrigatedandthedrainisplaced,therectusfasciaisclosed.FOOTHEAD
30EDGEOFRECTUSFASCIAItisimportantnottotiethroughtheentirerectusmuscle,asthismaycausenecrosisofpartofthatmuscle.
31Completedrunningclosureoftherectusfascia,withtheHemovacdrainemergingfromwithintherectusmuscle.HEADFOOTCOMPLETEREPAIRHEMOVACDRAIN
32APPOSTOPERATIVEVIEW
33INLETVIEW
34OUTLETVIEW
