General principles of surgical debridement and fracture management
Primary surgical debridement (PSD) in pelvic trauma has a number of specific features. The main difficulty lies in the deep anatomical location of the damaged structures.
Basic rules of surgical debridement:
- Radical excision: all non-viable tissues must be completely removed.
- Drainage: wide dissection of the pelvic fascial spaces is required. This is critically important because closed spaces impede adequate outflow of wound secretion.
- Anesthesia: absolutely all operations in this zone are performed under general anesthesia.
The scope of intervention is always determined by the level of the wound tract (peritoneal, extraperitoneal, or perineal compartments). The situation is often aggravated by concomitant pelvic bone fractures, leading to a sharp deterioration in the victim's condition.
For open pelvic ring fractures, surgical tactics include:
- Complete removal of all free-lying bone fragments.
- Rongeuring of crushed bone edges. Debridement continues until a section with preserved periosteum is exposed, which bleeds actively on the cut surface.
Antishock therapy: Shkolnikov-Selivanov blockade
Since pelvic injuries are often accompanied by severe traumatic shock, an essential stage of care is adequate pain relief. To resuscitate the patient from shock, a blockade of the lumbar and sacral nerve plexuses according to the Shkolnikov-Selivanov method is used.
Blockade technique:
- Injection point: the needle is inserted exactly 1 cm medial to the anterior superior iliac spine (spina iliaca anterior superior).
- Instruments: a long needle (14–15 cm) is used.
- Direction: the needle is advanced from front to back, guided by the inner surface of the iliac wing.
- Anesthetic administration: as the needle advances, the surgeon continuously infiltrates the solution ahead of it, creating a "creeping infiltrate". A total of 400–500 ml of a 0.25% novocaine solution is administered.
Intraosseous novocaine blockade can be used as an alternative method of pain relief.
Tactics for urinary bladder injuries
The surgical approach changes radically depending on the relationship of the wound to the peritoneal cavity.
Intraperitoneal compartment:
- Access is achieved via laparotomy.
- The wound is sutured with a reliable two-layer suture. The first layer is applied with catgut, strictly without involving the mucosa. The second layer is seromuscular, performed with fine silk.
- For adequate healing, an indwelling catheter is placed in the urinary bladder for several days.
Extraperitoneal compartment:
- Accessible areas of damage are also sutured with two rows of sutures (the second row captures the fascia and the muscular wall of the bladder).
- A mandatory addition to the operation is the placement of a suprapubic fistula (epicystostomy) for urinary diversion.
- אם the wound is located in the neck region and it is technically impossible to suture it, the surgeon is limited to placing a suprapubic fistula and achieving the widest possible drainage of the prevesical cellular space.
Tactics for rectal injuries
For injuries to the intraperitoneal segment of the rectum, emergency surgical intervention is required.
- Access: an emergency laparotomy is performed.
- Suturing: the bowel wall defect is closed with a two-layer suture. A mandatory step is peritonization of the sutured area using an omental flap.
- Fecal diversion: to exclude the passage of feces through the damaged area, an artificial anus (colostoma) is created on the sigmoid colon.
In extraperitoneal rectal injuries, tactics depend on the possibility of reliably suturing the defect and the need for adequate drainage.
Briefly: answers to topical questions
What is the surgical tactic for extraperitoneal rectal injuries?
Surgical tactics for rectal injuries consist of creating conditions for healing and sanitation. The main stages include:
- Primary surgical debridement — radical excision of damaged wound tissues.
- Wide drainage — adequate opening of the pelvic fascial spaces.
- Colostomy placement (colostoma) — formation of an artificial anus for fecal diversion.
Which pelvic fascial spaces may require drainage in pelvic organ injuries?
In pelvic organ injuries, deep fascial spaces where blood, urine, or pus accumulate may require drainage. These include:
- Prevesical space — drained in injuries of the bladder neck and phlegmon.
- Lateral fascial spaces — can be a source of purulent tracking.
- Retromeniscal space / Retrorectal space — involved when infection spreads.
- Visceral fascial spaces — affected along the course of blood vessels to the organs.
- Subperitoneal floor fat — can be drained through the ischioanal fossa.
What surgical approaches are used to drain deep pelvic fascial spaces?
Various surgical approaches are used to drain deep pelvic fascial spaces depending on the topography of the wound. The following options are used:
- Paraanal approach — used for rectal injuries.
- Parasacral approach — used to drain pelvic fat.
- Coccygeal incision — performed with resection of the coccyx and the lower two sacral vertebrae.
- MacWhorter-Buyalsky approach — used to open phlegmon of the prevesical space.
- Kupriyanov approach — also used for deep-seated abscesses of the prevesical fat.
What complications, besides traumatic shock, are characteristic of pelvic organ injuries?
In addition to traumatic shock, sources indicate the following complications and associated injuries:
- Pelvic bone fractures — frequently accompany injuries to the pelvic organs and sharply worsen the patient's condition.
- Intestinal and iliac vessel injuries — most commonly associated with concurrent ureteral injuries.
- Urinary extravasation and phlegmon — possible in bladder injury or unrecognized ureteral trauma.
- Urinary peritonitis and purulent pyelonephritis — complications of unrecognized ureteral trauma.
- Ureteral stricture — a possible complication of unrecognized ureteral trauma.
- Urogenital and combined fistulas — may be of traumatic origin.
Injection point for the Shkolnikov-Selivanov block: 1 cm medial to the anterior superior iliac spine. Easy to remember: "One step inside the spine" (spina iliaca anterior superior).
Class and exam questions
What anesthesia is used during primary surgical debridement of pelvic wounds?
Any surgical interventions for such injuries are performed exclusively under general anesthesia.
What is the essence of debriding open pelvic bone fractures?
The surgeon removes all freely lying bone fragments and trims the damaged bone edges down to a bleeding area covered with healthy periosteum.
How are intraperitoneal bladder wounds sutured?
A two-row suture is used: the first row is applied with catgut without capturing the mucosa, the second is a seromuscular suture using fine silk.
What should be done if an extraperitoneal wound of the bladder neck cannot be sutured?
In such situations, a suprapubic fistula (epicystostomy) must be created, and wide drainage of the prevesical cellular space must be provided.
What else to study on this topic
- Topographical anatomy of the lesser pelvis fascial spaces
- Technique for Suprapubic Fistula (Epicystostomy) Placement
- Creation of an Artificial Anus (Colostomy)
- Surgical Tactics in Extraperitoneal Rectal Injuries
- Intraosseous Novocain Blockade in Pelvic Trauma
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