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, 3 (4), 269-73

Risk of Spermatic Cord Injury During Anterior Pelvic Ring and Acetabular Surgery: An Anatomical Study

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Risk of Spermatic Cord Injury During Anterior Pelvic Ring and Acetabular Surgery: An Anatomical Study

Reza Firoozabadi et al. Arch Bone Jt Surg.

Abstract

Background: Anterior pelvic ring surgery includes a variety of plating techniques and insertion of retrograde superior pubic ramus screws. Anterior acetabular surgery also includes fixation through an ilioinguinal or Stoppa approach. These exposures risk injury to the spermatic cord and accompanying genital branch of the genitofemoral nerve. The primary aim of this study was to identify the distance between the midline and the spermatic cords in adult male cadaveric specimens. The secondary aim was to determine spermatic cord diameters and measure the distance between the spermatic cord and implant during instrumentation of a retrograde superior pubic ramus medullary screw.

Methods: Extended Pfannenstiel and Stoppa approaches were performed on 18 embalmed male cadavers bilaterally. Spermatic cord characteristics were recorded and a number of measurements were performed to determine the distance of implants and the midline from the spermatic cord.

Results: The average distance between the midline and spermatic cords was 34.2 mm. The average distance between the spermatic cord and implant was 18.2 mm. Eleven of the thirty-six dissections had abnormalities including cord lipomas and inguinal hernias. The average cord diameter was 18.6 mm. The average cord diameter in those with abnormalities was 24.9 mm and 16 mm in those without abnormalities, this difference was statistically significant.

Discussion: Due to the proximity of the spermatic cord, the surgeon should either formally expose the cord or limit lateral dissection from the midline during Pfannenstiel and Stoppa exposures. Similarly, the surgeon should use soft-tissue sleeves and oscillating drills to avoid injury to the contralateral spermatic cord during the insertion of retrograde superior pubic ramus medullary screws.

Keywords: Acetabular surgery; Ilioinguinal approach; Retrograde ramus screw; Spermatic cord; Stoppa.

Figures

Figure 1
Figure 1
Normal Inguinal Anatomy. The external (superficial) inguinal ring is an opening in the external oblique aponeurosis. It is the end of the inguinal canal and allows passage of the spermatic cord and the genital branch of the genitofemoral nerve. The ilioinguinal nerve course is variable. It often pierces the external oblique aponeruosis cephalad to the superficial ring, but sometimes exits through the external inguinal ring along with the spermatic cord. As the spermatic cord descends to the testicle, it travels anterior to the external oblique aponeurosis, lateral to the pubic symphysis, and anterior to the superior pubic ramus.
Figure 2
Figure 2
Spermatic Cord and Retrograde Ramus Screws. a) The Kirshner wire simulates the trajectory of the drill bit and screw. The penrose drain simulates the course of the spermatic cord. b) CT scan shows the spermatic cord in cross section and proximity to the pubic tubercle. The trajectory of the drill bit and screw (white line) requires a stab incision over the contralateral pubic tubercle. Subcutaneous dissection allows the drill bit and screw to enter the ipsilateral pubic tubercle. The drill bit and screw are in close proximity to the contralateral spermatic cord.
Figure 3
Figure 3
Inguinal Anatomy Deep Layer. The transverses abdominus muscle lies below the internal oblique muscle. The internal (deep) inguinal ring is an opening in the transverses abdominus muscle and is the origin of the inguinal canal.
Figure 4
Figure 4
Retrograde Superior Ramus Screw. AP Pelvic radiograph showing retrograde screw stabilization of the superior ramus component of a pelvic ring injury.

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