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Anterior Ilioinguinal Approach
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- 1. Corona mortis (anastomosis between external iliac [inferior epigastric] and internal iliac [obturator] vessels behind superior pubic ramus)
- Spermatic cord
- LFCN which is 3cm medial to ASIS
- Femoral nerve below inguinal sheath
- Position – Supine with ipsilateral Greater Trochanter at edge of bed, bump under ipsilateral buttock
- Incision – Curved incision along iliac crest to 2cm above symphysis
- Dissection (proximal) – Release External Obliques and subperiosteal dissection along ilium to expose SIJ greater sciatic notch
- Dissection (distal) – Divide External Obliques → identify spermatic cord → divide Internal Obliques, transversalis muscle, and rectus abdominis muscle, ligating inferior epigastric vessels → Push peritoneum upward to reveal femoral NVB and iliopsoas (separate by incising iliopectineal fascia) → identify and ligate corona mortis
- Create the 3 windows
- Lateral = lateral to iliopsoas
- Middle = Between Iliopsoas and femoral NVB [incise iliopectineal fascia]
- Medial = medial to Femoral NVB
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Anterior Modified Stoppa
- Compared to ilioinguinal approach:
- Advantages: preservation of LFCN
- Disadvantages: Unable to access lateral window unless extended
- Incision – Pfannenstiel incision 2cm above symphysis
- Dissection – Split linea alba vertically → enter space of Retzius → sharp dissect rectus off the superior pubic ramus → identify and ligate corona mortis → incise iliopectineal fascia (between femoral NVB and iliopsoas) to reveal the middle and medial windows
- Extension – Addition of lateral window (similar to proximal aspect of ilioinguinal approach)
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Anterior Iliofemoral Approach - most extensile but highest risk of HO, hardly used now
- Detaches origins of TFL and Sartorius
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Posterior Kocher-Langenbeck
- Indications – Posterior wall/column, T-type Fractures, ABC
- Dangers – Superior Gluteal Nerve, Sciatic nerve, MFCA, Corona Mortis
- Incision – PSIS to GT along shaft → ITB, Glute Max, protect SGN (5cm)
- Dissection – Excise bursa, identify Short External Rotators with hip in internal rotation, detach piriformis, obturator internus 1.5 cm from insertion (to protect medial femoral circumflex artery)
- Extensile with Greater trochanter osteotomy
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O simple ones, learn prudence; O fools, learn sense. Proverbs 8:5