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Atlas of Trauma
Extraperitoneal Approach to the Iliac Vessels
Karim Brohi, trauma.org 7:12, December 2002
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.
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