Buyalsky–MacWhorter surgical approach
Pelvic fascial space drainage according to Buyalsky and MacWhorter requires specific patient positioning on the operating table, ensuring the surgeon's safety and convenience. The patient is placed in the classic supine position, with lower limbs flexed at the knee joints and abducted as far as possible. In surgical practice, this position is often called the “frog-leg position.” It provides optimal visual and instrumental access to the medial surface of the thigh and perineal structures.
Surgical access is performed through a linear skin incision about 8–9 centimeters long. The incision line runs along the inner surface of the thigh. An important visual and palpable landmark for the operating surgeon is the muscular elevation formed by the contours of the gracilis muscle (m. gracilis) and the adductor longus muscle of the thigh. The incision is made not in the crease itself, but approximately 3–4 centimeters inferior to the femoroperineal crease to avoid damaging superficial structures in this area.
Layer-by-layer dissection and Buyalsky–MacWhorter drainage
After dissecting the skin and subcutaneous adipose tissue, the surgeon must carefully navigate through the muscular mass of the thigh for safe penetration into the pelvic cavity.
Main stages of deep dissection:
- Isolation and subsequent transection of the adductor brevis muscle of the thigh. This surgical step provides a wide exposure of the underlying obturator externus muscle.
- Passing through the obturator foramen of the pelvis. The surgeon sequentially dissects the obturator externus muscle, the dense connective-tissue obturator membrane, and the obturator internus muscle. At this stage, it is critically important to maintain the correct incision direction: the scalpel must follow strictly along the inferior ramus of the pubis.
- Having successfully overcome this musculo-fascial barrier, the operator penetrates directly into the paravesical tissue, where the pathological content accumulates.
The operation concludes with the mandatory placement of drainage tubes into the formed cavity. The wound is closed in layers, leaving a free exit for the inserted drain, which ensures adequate outflow of discharge in the postoperative period.
Kupriyanov drainage technique
An alternative and equally effective method for draining pelvic fascial spaces is the surgical technique proposed by Kupriyanov. Unlike the femoral approach by Buyalsky and MacWhorter, this method uses a classic lower midline incision, i.e., a laparotomy is performed for access through the abdominal wall.
After opening the abdominal cavity and thoroughly revising the pelvic organs, the surgeon uses a long blunt instrument—a ring forceps (long clamp). It is carefully advanced through the narrow anatomical space bounded laterally by the side wall of the urinary bladder and medially by the medial edge of the levator ani muscle (m. levator ani).
Advancing the instrument inferiorly, the surgeon bluntly punctures the urogenital diaphragm. Then, using the tip of the clamp, the perineal skin is protruded from the inside near the inferior border of the pubic ramus. A small skin incision is made over the most prominent area. Through the resulting opening, the jaws of the clamp grasp the drainage tube and pull it through the formed wound channel directly into the pelvic cavity.
The scope of the surgical intervention according to Kupriyanov's method may vary: drainage is performed unilaterally or bilaterally. The choice of final surgical tactics depends directly on the severity of the inflammatory process and the extent of involvement of the fascial spaces.
Briefly: answers to topical questions
Which lesser pelvis fasciae limit the paravesical fascial space?
The paravesical fascial space is limited by the visceral fascia, fascial lateral flaps, and the prevesical fascia. The visceral fascia limits the visceral fascial spaces, including the paravesical space; the fascial lateral flaps separate the prevesical space from the lateral spaces of the lesser pelvis; the prevesical fascia forms the posterior border of the prevesical space and extends onto the urinary bladder.
In which pathological conditions is paravesical space drainage indicated?
Drainage is indicated for abscess formation, tissue necrosis, and pelvic phlegmon. In pelvic phlegmon or grade 3–4 fistulas, surgical drainage is combined with diverting colostomy.
To remember the Buyalsky–MacWhorter approach: “The frog jumps through the obturator foramen to the urinary bladder” (patient in the “frog-leg position,” surgeon cuts through the obturator muscles and membrane to reach the paravesical tissue).
Class and exam questions
What position is given to the patient during Buyalsky-MacWhorter surgery?
The patient is placed in a supine position with knees flexed and legs abducted. In surgery, this position is known as the "frog position".
Where exactly is the obturator complex dissected during the thigh approach?
The obturator externus muscle, membrane, and obturator internus muscle are dissected strictly along the inferior ramus of the pubic bone.
What surgical approach is used in Kupriyanov's technique?
Unlike the femoral approach, Kupriyanov's method uses a lower midline incision (laparotomy).
Between which structures is the ring forceps passed according to Kupriyanov?
The instrument is advanced in the space between the lateral wall of the urinary bladder and the medial edge of the levator ani muscle (m. levator ani).
What else to study on this topic
- Topographic anatomy of the paravesical fascial space
- Medial thigh muscles: gracilis, adductor longus, and adductor brevis
- Structure of the obturator complex: muscles and membrane
- Anatomy of the urogenital diaphragm and levator ani muscle (m. levator ani)
- Indications for unilateral and bilateral pelvic drainage
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