Modified Stoppa approach is a surgical approach used for fixation of the pelvic fracture with improved visualization of both the columns.
Indications
- Incongruent hip joint
- Associated both columnar fractures
Advantages
- Improve visualization of columns
- Direct instrumentation of the quadrangular surface
- Easy control of corona Mortis
- Easy access to the pubic symphysis
- Reduce dissection of the inguinal canal
Disadvantages
- Difficulty in reducing small peripheral ant. wall fragments a/w the anterior column fracture.
Surgical procedure for Modified Stoppa Approach
Supine position
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The surgeon stands on the opposite side of the fracture
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An injured leg is included in the surgical field with a sterile wrapped/bolster or triangle beneath the knee
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Skin incision( Pfannenstiel incision)
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Subcutaneous tissue divided in the line of incision: Exposure of fascia overlying both rectus muscle of abdomen
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Rectus fascia incised in a longitudinal fashion in the line of linea aspara
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Both bellies of rectus abdominis muscles are gently retracted laterally
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Care should be taken not to incise the peritoneum proximally
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The entire approach is done in pre-peritoneal space
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The medial part of rectus femoris is partly detached from the upper and anterior part of symphysis on the side of the fracture to be retracted
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The upper border of superior pubic rami is identified (pectes pubis) and blunt dissection using a finger or swab is corrected laterally using along the pelvic brim without incising fascia
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Corona Mortis vessels ligated (mostly venous) on the medial side of superior rami
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Thick periosteum from superior pubic bone dissected sharply using diathermy till Ilio-pectineal eminence
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Ilio-pectineal arch is dissected from bone
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Elevates femoral nerve and vessels
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At this level, obturator neurovascular bundle is crossing quadrangular surface
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Spatula or malleable retractor is used to protect obturator neurovascular bundle
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Psoas and vessels retracted laterally
Obturator bundle and bladder: medially
Lateral window: Can be made along iliac crest starting 2 cm posterior to ASIS following iliac crest posteriorly
Dangers/Complications following the Modified Stoppa approach
- Injury to obturator nerves/vessels, Corona Mortis, External iliac vessels, bladder
See also: Surgical approaches to Spine
