- Ilioinguinal approach
The ilioinguinal approach was developed by Emile Letournel based on cadaveric dissections to provide anterior access for fractures of the acetabulum.
It provides exposure of the inner aspect of the innominate bone from the sacroiliac joint to the pubic symphysis.
The surgical exposure requires development of three wound intervals. Mobilization of the femoral vessels and nerve, as well as the spermatic cord (male) or round ligament (female), is key to the development of these intervals.
Articular reductions, using the ilioinguinal approach, are done indirectly. They are based on meticulous restoration of extraarticular anatomy, since the joint can not be directly visualized with this approach.
Our image shows
- in dark brown: Direct access
- in light brown: Secondary access for clamp placement or limited visualization
The ilioinguinal approach is used for virtually all fractures of the anterior wall and anterior column as well as associated anterior plus posterior hemi-transverse patterns.
In addition, the majority of both column fractures can be operated using the ilioinguinal approach.
Lastly, an occasional transverse or T-shape fracture may be treated using this approach.
Make a curved incision beginning posterior to the gluteus medius pillar and
extend past the midline 2 cm proximal to the symphysis.
In case of thin individuals, placing the lateral limb of the incision distal to the ilioiliac crest may avoid a tender scar.
Expose the internal iliac fossa
Begin by exposing the internal iliac fossa. Release the external oblique
insertion onto the iliac crest, taking care to leave a thick fascial/
periosteal cuff to facilitate repair.
Initially, leave the tissues attached to the anterior superior iliac spine.
In continuity with this release, expose the internal iliac fossa
subperiosteally by mobilizing the iliacus muscle.
Pack the fossa with a sponge.
Next, the external oblique aponeurosis is incised from the anterior superior iliac spine (ASIS) to the lateral border of the rectus sheath, passing cranial to the external inguinal ring.
Release the muscular attachment from the inguinal ligament
The spermatic cord (or round ligament) is mobilized in the medial aspect of the wound.
Medially the transversus abdominis is then released from the inguinal ligament, usually taking 1-2 mm of the ligament with the tendon.
This release begins at the anterior superior iliac spine and progresses medially to the conjoint tendon of the internal oblique, and the pubic tubercle.
Care must be taken during this portion of the procedure to protect the ilioinguinal nerve which normally lies just proximal to the inguinal ligament after penetrating the abdominal wall.
Secure the lateral femoral cutaneous nerve
The lateral cutaneous nerve of the thigh is usually encountered just deep to the conjoint tendon (of the internal oblique and the transversus abdominis) approximately 1-2 cm medial to the anterior superior iliac spine.
This nerve can usually be preserved if it is mobilized as it exits the abdominal wall and enters the fascia of the thigh.
The anterior aspect of the iliopsoas muscle is thus exposed in the lateral portion of the wound with the femoral nerve lying on its anteromedial surface.
Femoral canal anatomy
The key to understanding the next portion of the dissection is the anatomy of the femoral canal and the iliopectineal fascia.
This fascia separates the neural and vascular compartments and blocks access to the true pelvis from the internal iliac fossa.
Develop the iliopectineal fascia
The iliopectineal fascia is delineated by careful retraction of the femoral
vessels medially and the femoral nerve and iliopsoas laterally.
It is then divided distally, under direct visualization, down to the pubic root.
Release the iliopectineal fascia
The iliopsoas is then retracted laterally, exposing the fascial attachment to the pelvic brim which can be divided safely.
Once the iliopectineal fascia has been released, the true pelvis can be entered from the internal iliac fossa.
Dissection around the iliac vessels should be minimized. This limits risk of vascular injury and also preserves the path of the primary lymphatic trunk to the lower extremity which passes medial to the vein.
The 3 windows of the ilioinguinal approach can now be fully exploited.
The first window encompasses the entire internal iliac fossa from the sacroiliac joint posteriorly to the iliopectineal eminence anteriorly.
This window is optimized with hip flexion to relax the iliopsoas.
Medial retraction usually requires placement of retractors on the quadrilateral surface.
The second window provides access to the pelvic brim and quadrilateral surface from the sacroiliac joint to the lateral third of the superior pubic ramus. Medial retraction of the femoral vessels should be gentle and must be carefully monitored.
The third window can be developed in a number of different ways. The most limited of these leaves the ipsilateral rectus insertion attached and visualization is provided between the rectus and the spermatic cord (or round ligament).
Alternatively, if the fracture pattern requires, the entire medial portion of the superior ramus and symphysis can be visualized by release of the ipsilateral rectus insertion.
The same visualization can be achieved by leaving the rectus attached and splitting the rectus heads in the midline. With the rectus still attached, retraction is carried out posterior to the rectus with a Hohmann retractor placed along the superior ramus.
Operating surgeon switches sides
All three variations require that the bladder be protected. This can be achieved by packing the prevesicular space with a sponge after the bladder has been identified by palpation of the urinary catheter bulb.
It is frequently useful for the operating surgeon to perform the third window exposure from the opposite side of the table for optimum visualization.
This provides a view from the symphysis looking laterally along the superior ramus and pelvic brim.
This exposure can be developed further to include the entire pelvic brim and quadrilateral surface.
The third window developed in this manner provides surgical access equivalent to the modified Stoppa approach.
Retropubic vascular anastomoses
From the opposite side of the patient, one can more easily see any retropubic vascular communications between the obturator vessels and either the inferior epigastric (corona mortis) or external iliac vessels. Such retropubic anastomoses, present in 40% or more of patients, are at risk of being torn. They may require ligation and division to allow mobilization of the iliac vessels.
Before closure, one may place drains in the space of Retzius and anterior internal iliac fossa.
Layered closure then begins with repair of the conjoint tendon to the inguinal ligament. A careful fascial repair restores the floor of the inguinal canal.
The external oblique aponeurosis and the rectus sheath are then repaired, followed by secure reattachment of the abdominal wall origin to the iliac crest, in the lateral portion of the incision. A hernia-free repair, and avoidance of entrapment of the spermatic cord should be achieved.
Subcutaneous drains may be inserted.
Finally, perform an appropriate subcutaneous and skin closure.