| Introduction
This approach is useful for access to the external iliac
vessels, internal iliac origin and the common iliac vessels.
It may be extended higher, essentially as an extraperitoneal
approach to the aorta, inferior vena cava & kidneys.
However, a midline laparotomy approach is usually more
appropriate for adequate exposure and control of these
proximal vessels.
The following images were taken of a patient with thrombosis
and possible intimal injury of the external iliac artery
following angiography for pelvic trauma. Initially the
puncture site was explored as a routine exposure of the
common femoral artery.
Technique
A vertical incision is made over the mid-point of the
inguinal ligament (over the femoral pulse, if there is
one). The inguinal ligament is an important landmark here.
A common mistake is to make the incision too low, at the
level of the groin crease, rather than at the inguinal
ligament.
The incision is carried downwards, opening the femoral
sheath to expose the femoral artery. The loose adventitia
around the artery is divided and the artery exposed along
it's length.
At this point it was clear that more proximal exposure
would be needed, and the incision was extended to the
extraperioneal 'hockey-stick' incision.
The incision is extended proximally, and curved laterally
if the incision extends above the iliac crest.
Dissection is continued downwards to the external oblique.
The aponeurosis and abdominal wall musculature are divided
in line with the incision, lateral to the internal ring,
avoiding cord structures.
There is a rather troublesome vein just beneath the inguinal
ligament. Ideally it's better to ligate this before you
cut it!
The peritoneum and its contents are swept medially to
expose the iliac vessels. These can be controlled with
slings by passing a curved (Lahey) forceps around the
vessel from medial to lateral. The iliac veins are closely
related to the arteries and care must be taken not to
damage them during this manoeuver. The image below shows
control of the common iliac (white), internal iliac artery
(orange), and common femoral (orange) arteries. The blue
sling is around the ureter.
trauma.org (7:12) December 2002 |
