Ilioinguinal, Extended Iliofemoral, and Combined Approaches

Ilioinguinal, Extended Iliofemoral, and Combined Approaches

William A. McGann

Aaron G. Rosenberg

Ilioinguinal Approach

The ilioinguinal approach is a modification of the Smith–Petersen iliofemoral approach. It was modified by Judet and Letournel to gain access to the anterior aspect of the pelvis and the acetabulum where exposure is needed distal to the iliopectineal eminence. Exposure proximal to the iliopectineal eminence is adequate using the classic iliofemoral approach. The ilioinguinal approach allows access to the inner ilium, the inner surface of the true pelvis and sacroiliac joint, the quadrilateral plate to the spinous process and obturator foramen, the anterior column to the superior pubic ramus, and the symphysis pubis. The outer aspect of the ilium can also be exposed by the release of the abductors, but this exposure is at the expense of bone circulation, which may be detrimental, especially in fracture work. Heterotopic ossification is not considered a major risk with this approach if the abductors are not released. This approach does not allow direct access to the hip joint unless there is acetabular bone disruption, such as a fracture.

Indications for this approach include fractures, reconstructions, tumors, and periacetabular osteotomies. Pelvic fractures of the anterior wall or anterior column, and T-type acetabular fractures can be readily exposed and successfully fixed using this approach.

The patient is positioned supine for the approach, with the affected side elevated between 0 and 30 degrees. Alternatively, a bolster may be placed beneath the sacrum to elevate the pelvis from the table and thus facilitate maneuverability of the pelvis and soft tissue. Extending the drapes to beyond the opposite iliac crest and upper abdomen facilitates orientation and exposure for this approach. A Foley catheter is desirable to decompress the bladder and allows proper retraction of deep tissues for improved exposure.

The incision can be considered to be a combination of two limbs: one medial and the other lateral (Fig. 9.1). The medial limb extends from 2 or 3 cm above the symphysis pubis toward the ASIS, and the lateral limb extends posteriorly from the ASIS to beyond the gluteus medius tubercle of the iliac crest. The incision may be placed more caudad to the iliac crest to avoid late incisional pain caused by irritation from tight garments.

The deeper exposure is initiated at the lateral limb by elevation of the external oblique from the iliac crest (Fig. 9.2). It is important to extend the dissection far enough posteriorly into the external oblique, which becomes muscular as it inserts into the iliac crest. Subperiosteal dissection of the iliacus muscle medially toward the iliac fossa is carried posteromedially to the level of the capsule of the sacroiliac joint.

In the medial limb, the external oblique fascia is incised parallel and just proximal to the inguinal ligament as far medial as the external inguinal ring (Fig. 9.3). In males the spermatic cord is isolated, whereas in females the round ligament is isolated. The inguinal canal is then opened by dissecting the lower flap of the external oblique aponeurosis. The ilioinguinal nerve is visible as it penetrates the internal oblique musculature. The internal oblique and transverse abdominis fascia are incised adjacent to the conjoined tendon and beneath the spermatic cord. The internal oblique and transverse abdominis can then be mobilized from the inguinal ligament. The inferior epigastric artery crosses the floor of the inguinal canal at the medial border of the deep inguinal ring and requires ligation. In the lateral portion of the dissection, the lateral femoral cutaneous nerve can be identified as it penetrates 1 to 3 cm medial to the ASIS. This nerve may be either preserved or transected. The transversalis fascia can then be incised while preserving an inferior flap of a few millimeters for later reapproximation. (This fascia covers the lymphatic and vascular compartments.) Medially, the transversalis fascia can be dissected off the inguinal ligament and the rectus abdominis fascia. Further exposure of the symphysis can be carried out by release of additional rectus fascia to include the contralateral rectus tendon.

In the deep wound, the tissue adjacent to the iliopsoas compartment can now be incised. Adjacent to the femoral nerve can be found the iliopectineal fascia, which is a continuation of the investing fascia of the iliopsoas (Fig. 9.4

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May 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Ilioinguinal, Extended Iliofemoral, and Combined Approaches

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