The first use of laparoscopy to treat pelvic ring fractures:
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Highlights

• This “laparoscopic internal fixation” delivered an in situ result as good as that of open surgery.

• Despite a long operating time, the blood loss was very low

• This technique opens a new approach to the treatment of pelvic fractures,

A 34-year-old male without medical or surgical history was admitted to the intensive care unit of our level 1 trauma center after a road accident. He had severe head and pelvic ring injuries. Emergency pelvic radiographs and computed tomography revealed a lateral compression fracture with internal rotational instability; fracture of the left sacral wing (Denis grade 1) was associated with bilateral fracture of the obturator bone frames (grade AO/OTA 61B2.1b). They decided to fix the posterior arch of the pelvic ring, but also the anterior arch, as recommended by the AO. Surgery was performed by senior trauma (RDF) and urological (JM) surgeons. They first inserted two, left, sacroiliac cannulated screws via a classical percutaneous approach aided by inlet and outlet fluoroscopic views. They next performed laparoscopy.

The peritoneal cavity was entered using an open laparoscopy technique via a 10/12-mm optical trocar positioned below the umbilicus. The pneumoperitoneum was insufflated to 12 mmHg and the intestinal loops repressed by placing the patient in the accentuated Trendelenburg position. Two further 10/12-mm trocars were added, triangulating the left and right pararectal areas. The Retzius space was opened using bipolar forceps and monopolar scissors. Dissection proceeded to the endopelvic fascia covering the base of the prostate. A fourth trocar (10/12 mm) was then created in the pubis to allow passage of instruments required for screw insertion. The pubic arch was carefully dissected. The right and left coronae mortices were ligated with bipolar forceps. Use of a monopolar hook and a dissector facilitated release of the pelvic bone surface. After dissection was adequate, a 10-hole, Matta curved plate was inserted through a trocar and retrieved using forceps. When the plate was appropriately positioned on the anterior arch of the pelvic ring, it was fastened using a ball-spike pusher inserted into a trocar.

A plate screw inserter (associated with a long drill guide) was then sequentially introduced into the various trocars to ensure appropriate orientation of all screws. The two key screws (those at the ends of the plate) were first inserted using a long screwdriver. When the plate was stably fixed to the bone, the other screws were inserted. All screws required for reliable fixation were successfully inserted. Fluoroscopy was then performed. Given the space required by the laparoscopic instruments and surgical manipulation, screw placement under direct fluoroscopy was impossible. The surgery required 4 hours; blood loss was less than 100 mL, reflecting, principally, evacuation of a hematoma. They encountered no intraoperative complications; the patient did not react negatively to laparoscopy, and the postoperative X-rays were satisfactory. Unfortunately, the patient died from his head trauma 16 days after the accident.

Source:https://www.sciencedirect.com/science/article/pii/S221026122030835X?dgcid=rss_sd_all
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