April 11, 2024

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

The surgeon stands on the opposite side of the fracture

An injured leg is included in the surgical field with a sterile wrapped/bolster or triangle beneath the knee

Skin incision( Pfannenstiel incision)

Modified Stoppa approach Pfannenstiel incision

Subcutaneous tissue divided in the line of incision: Exposure of fascia overlying both rectus muscle of abdomen

Rectus fascia incised in a longitudinal fashion in the line of linea aspara

Both bellies of rectus abdominis muscles are gently retracted laterally

Care should be taken not to incise the peritoneum proximally

The entire approach is done in pre-peritoneal space

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

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

Corona Mortis vessels ligated (mostly venous) on the medial side of superior rami

Thick periosteum from superior pubic bone dissected sharply using diathermy till Ilio-pectineal eminence

Ilio-pectineal arch is dissected from bone

Elevates femoral nerve and vessels

At this level, obturator neurovascular bundle is crossing quadrangular surface

Pfannenstiel incision dissection

Spatula or  malleable retractor is used to protect obturator neurovascular bundle

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