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

Document Type : RESEARCH PAPER

Authors

1 Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, Seattle, WA USA

2 Department of Orthopaedics Surgery, The University of Texas Medical School at Houston, Houston, TX USA

3 Orthopedic and Trauma Service of Oklahoma, Tulsa, OK USA

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


  1. Barei D, Bellabarba C, Mills W, Routt MJ. Percutaneous management of unstable pelvic ring disruptions. Injury. 2001; 32 (Suppl 1):33-44.
  2. Routt MJ, Simonian P, Swiontkowski M. Stabilization of pelvic ring disruptions. Orthop Clin North Am. 1997; 28(3):369-88.
  3. Routt MJ, Nork S, Mills W. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000; 375:15-29.
  4. Routt MJ, Simonian P, Grujic L. The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruptions: a new technique. J Orthop Trauma. 1995; 9(1):35-44.
  5. Cole J, Bolhofner B. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994; 305:112-23.
  6. Karunakar M, Le T, Bosse M. The modified ilioinguinal approach. J Orthop Trauma. 2004;18(6):379-83.
  7. Kottmeier S, Farcy JP, Baruch H. The ilioinguinal approach to acetabular fracture management. Oper Tech Orthop. 1993; 3(1):60-70.
  8. Letournel E. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.
  9. Andersen R, O’Toole R, Nascone J, Sciadini M, Frisch H, Turen C. Modified stoppa approach for acetabular fractures with anterior and posterior column displacement: quantification of radiographic reduction and analysis of interobserver variability. J Orthop Trauma. 2010; 24(5):271-8.
  10. Easton L. Hermann Johannes Pfannenstiel (1862-1909). Br J Obstet Gynaecol. 1984;91(6):538-41.
  11. Gray H. Gray’s Anatomy. Philadelphia: Lea & Febiger; 1985.
  12. Raman J, Goldstein M. Intraoperative characterization of arterial vasculature in spermatic cord. Urology. 2004; 64(3):561-4.
  13. Carilli S, Alper A, Emre A. Inguinal cord lipomas. Hernia. 2004;8(3):252-4.
  14. Heller C, Marucci D, Dunn T, Barr E, Houang M, Dos Remedios C. Inguinal canal “lipoma”. Clin Anat. 2002;15(4):280-5.
  15. Irwin T, McCoubrey A. Adult groin hernias. Surgery (Oxford). 2012;30(6):290-5.
  16. Lilly M, Arregui M. Lipomas of the cord and round ligament. Ann Surg. 2002;235(4):586-90.
  17. Nasr A, Tormey S, Walsh T. Lipoma of the cord and round ligament: an overlooked diagnosis?. Hernia. 2005;9(3):245-7.