Dr. Gholve assists pediatric urology team at Tufts in treating a cloacal exstrophy by sequentially closing the pelvic ring with controlled osteotomies.
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Table of Contents
- Salter Incision: One finger width below iliac crest, 1-2 cm proximal to ASIS
- Elevate External Oblique Muscle: Iliac crest exposed from ASIS to 1/2-3/4 the length
- Dissect Sartorius/Tensor Fascia Lata Interval: Protect and medially reflect lateral femoral cutaneous nerve
- Split Iliac Crest Apophysis
- Expose Inner & Outer Table of Ilium: Sub-periosteal dissection on medial and lateral surface
- Expose Sciatic Notch
- Cut from Crest to Sciatic Notch
Good morning. I'm Puru Gholve. I’m one of the pediatric orthopedic surgeons. Today I'm helping the urological team to close cloacal exstrophy. My part is pelvic osteotomy which will assist in closure of the cloacal osteotomy - cloacal exstrophy sorry. There are multiple and different types of pelvic osteotomies that are described to assist urological team to close the cloacal exstro - exstrophy. There is anterior oblique iliac osteotomy and that is the osteotomy that will be done today.
The approach used for the osteotomy is the sawdust incision which extends one fingerbreadth going along the along the iliac crest and going about 1 to 2 centimeter proximal to the anterior superior iliac spine. The incision deepens to the underlying tissues. The superior skin flap is retracted medially and the insertion of the external oblique muscle on the iliac crest apophysis is elevated and the iliac crest is exposed right from the anterior superior iliac spine going almost 1/2 to 3/4 of the crest. Anteriorly, plane is developed between the Sartorius and tensor fascia lata. The fascia in between the Sartorius and tensor fascia is dissected. The lateral femoral cutaneous nerve tie is protected, and that is kept with the Sartorius medially. This interval is deepened. The deep part of the rectus femoris is identified, and in this kid - and in general for bladder exstrophy - we don't need any further dissection to expose the hip, but the prow - PROW - the prow of the ilium that is the area between the anterior superior iliac spine and the anterior inferior iliac spine will be exposed. So dissection is just beneath the anterior superior iliac spine going up to the anterior inferior iliac spine, dissecting the muscle. The iliac crest apophysis is split along its length with the number 15 blade. When the splitting is done, it’s done with the sawing motion. Once the the iliac crest apophysis, with a thumb this split apophysis can be pushed medially and laterally. The medial half goes medially, the lateral half comes laterally, and then a subperiosteal dissection is carried on till the sciatic notch. This exposes the inner and outer table of the ilium. Once this is done, in small kids, we adjust with a scissor, about one to two centimeter behind anterior superior iliac spine. The pelvis can be cut right, starting from the iliac crest going towards the notch. The bone should be cut right up to the sciatic notch. Also, a light amount of skin traction or bucks traction is placed so that the osteotomy fragment does not migrant proximally.
Today, this will be the procedure that will be done on this kid, and we will talk through the steps once the procedure is being done.
These children tend to have very largely widely spaced pubic rami. That’s the ring of the pelvis. You can actually feel them here where my two thumbs are, and what we will do is create pelvic osteotomy to allow sort of inward hinging of the - of the pelvis so that we can close the pelvic ring. That is a crucial step in this operation because if you do not close a pelvic ring without tension, that increases the chances of dehiscence of the wound and extrusion of the bladder.
Something like this. So they’re making incision along the iliac crest, starting - just medial to the ASIs. So the planes are going to be very very small here. I want to go just more medial with the incision Knife please. And then go back also. Slowly increasing the incision. Sem, please, sem. Put this. Let’s move the sem posterior a little. You also. So you can see now there's some muscle change here. That should be Sartorius to start up immediately because it's externally rotated spine. Your tensor is going to be more on this side like this. So I will confirm this is Sartorius - TFL. Far from it. Okay, agree - that's your TFL. Sartorius is more in the front. Yeah, yeah. I just want to get little exposure here like this. So you can come this way and hold it like this. So I’m going to elevate a little bit of this stuff here. Okay. It will appear, once you - that's Sartorius on that side. Let’s elevate the external oblique fascia before we go in there.
So once we find that place, it's not hard. Let's do little posterior side dissection here. We are taping this, right? So we are done incision along the - just beneath the iliac crest. Right now I'm elevating the external oblique muscles - muscle - from the top of the iliac crest. So I - this is the anterior superior iliac spine and the crest is going all the way back here, so I'm on the top of the crest here. Important to know, the TFL and Sartorius muscles. So this is the Sartorius muscle go medially - this muscle - and from here backward, this is the tensor fascia lata. So we are going to go through the tensor fascia lata into the start of the start of this TFL interval. Right now, we want to do little more exposure of the iliac crest. Just trying to go as back as possible here. Thank you. If you want to zoom in, I can show you. This is the exposed iliac crest. So this is the top of the iliac crest. Apophysis are exposed and this is anterior superior iliac spine and the crest is exposed up to here.
I’m happy with the exposure here, right? So far yeah. Let’s go to the TFL side now. Sartorius is in front of you. That's Satorius. Can you hold this retractor for a minute? Good, so we are opening from here now. So I can see the fibers of TFL here. I'm just pushing these fibers laterally. I want to be sure that I don't - this is the end over here.
So we’ve exposed the Sartorius TFL interval, and we can see the rectus femoris into the depth of it. Our next step is to cut the iliac crest. You want to keep your finger on the crest. Looking for the crest... So the crest has been cut little bit on the inside - that should not make any difference. So we are elevating the iliac crest. Might want to just spackle Ray-Tec here. The superior dissection will just keep on oozing on you otherwise. Normally, I’m able to just shove it in full Ray-Tecs here. You can see how much it’s going in here. Let’s do the anterior dissection here now. Where are the ASI’s? This is the ASI here - we’re going to connect this dot here. You are good - you're not going to the lateral decubitus nerve, which is more medial. Can you hold hold this one for a minute?
I’m usually not able to position it - that's the hardest part. Okay.
Hard to get... the baby’s too small. I’m quite sure that it is here - let’s see if we can see it from this side. It's harder from outside to inside - inside to outside is the way to do it. I can take the suction in my hand for a minute.
So, granted you can peek in, the right angle snap is passing beneath the sciatic notch. You can see starting from the inside of the sciatic notch and coming of the outer ilium. Now we are going to do the osteotomy. Osteotomy is about a centimeter behind the ASIs. Now the last part of the osteotomy I do with the - intuitively. You are holding it, right? You can see that tough structure that needs to be released. There’s the deep periosteum. So I’m going to cut it out ultimately. But I don’t want it to come out - I want it to straight come out so everything should be cut there.
He’s really moving now. Yes. There’s nothing that can hold this. I think the hole is so small - it's impossible to get a pin in there. Irrigation please.
So for description, just try to cut this vine. Otherwise, it's hard to close. The first one goes around it, so can you go through the apophysis? Alright, the closure looks good. I wouldn’t do any nylon on that - it’s good.
Probably more like here, huh? Do you mind running some problem on this side? The sac is coming all the way to the incision. I’m going to try to avoid it as much as possible. I think it goes like back here - yeah. It’s a mobile window though. The crest is here.This is the top. You'll see on the inside. You can see this is the top of the crest - that is the inside. Knife please.
That’s the ASIs - you can't go beyond that. That's Satorius, right? Yeah. Just go slow and steady - I’m just afraid for the - can I get pull please? Get me a skin knife first - got to go a little posterior. You’re really close to the pouch - yeah. That’s - that might be sac. Yeah - that might be sac there. I will be able to dissect around it anyways.
That should be fine, right? Now want to divide up here - expose the… I don’t think we should be going more than this, right? There’s little elevation here. That’s good. Let’s go to the TFL now. I might have taken on a little Sartorius there looks like, right? Yeah, looks like it.
Can you put the other side of the retractor in there? Yeah that's good. I’m going to delve out of the plane right now. That’s fine - that’s the ASI. This is - I’m not going to expose too much of the crest this time. We’re starting to do minimal as much as possible, right? I’m a little outside - that’s why it bled. Let’s get out of this plane here for TFL. Can I get a Freer please? Pick ups please. There’s the TFL okay, that here and that one there, okay? You got to get the fat off. That’s good. Please just to me here. Come in here and bring double. Come in there and double. Can I let go? This one - this one - this one. Come in there double. That’s good. Very good. Ray-Tecs please - just plunge it down - yeah, just back in there.
So let me make cut a little posterior here, otherwise we won’t be able to see anything. You can keep the bone wax away from it - I’m just going to use the Freer. You don't go out there - you really can't retract stuff. Freer back please. A little bit tight on this side, but I had anticipated that. Let’s see what we can do on this side here. Let’s see if we can get to it from this side. Just leave it like this here. This is not subperiosteal - it is not subperiosteal. Okay. Start right there? See that’s a subperiosteal plane - one single misstep and it will cause bleeding. With kid again falling too much in the supination - that’s the problem. You want to hold the pelvis - that is the right thing you are doing, holding the pelvis. What happened to the sciatic notch here all the way. Good ahead. So you can hold this one here. Come alongside now - I need a right angle snap. I’ll hold this one - you can hold the pelvis for a minute. I have not gone on this side yet - we got there - no I didn’t. Okay got this like this - keep the leg like this down.
So what’s happening is some of this periosteum is still hinged to here, but there’s no subperiosteal dissection. This the outer table - see here? If you take this thing down, that will help. But this tissue was blocking us. Okay. I should be able to see here now - so might help if you just pull back a little bit. Can I get another right angle snap please? I think we are there - it’s just... we are falling into the crest here. That’s it - that’s the sciatic notch. We should start to see a little bit better now. Stop here - you - you are there. So pull back a little bit. Turn towards me - no the other way around. Yeah - now - it just sticks into the soft tissues. We don’t - don’t want the osteotomy to be too much in the front though. Then we can get our exposure though, right? How many excuses... Yeah - you’re fine. Yeah, that’s the part. He’s in there now. Just hold it. That’s good - that’s hinged - that’s hinged.
We can just start the osteotomy - I can see here. Yeah, there I am. Where? Just touching your tip. I don’t know - I don’t see you. Hold this there for a minute - don’t push it - come back to me. Now you can come out with the Freer. Just the tip of the periosteum not allowing you to move.
Pick up. You are... that fragment - let me hold it. Yep. Don’t take too much of it - just a fair part. I’m going to take a little more from here - this part. More? You can close it.