B
Vascular Injuries in the Groin
David J. Williams
576
Penetrating wounds to the groin are usually below the inguinal ligament (Figure B-1), and so can be approached by a standard vertical incision with control of the proximal and distal vessels (Figure B-2). In the author’s expe- rience, if one can place one’s fingers between the site of femoral injury and the inguinal ligament, then the dissection should be possible. This allows the common, superficial, and profunda femoris vessels to be looped, bleed- ing controlled, and repair or ligation performed. If the injury extends un- expectedly proximally, the inguinal ligament can be cut vertically to allow access to the distal external iliac; however, one must be careful not to divide the bridging vein, which is just under the ligament, or there tends to be addi- tional bleeding.
If the femoral injury is high, a direct approach may not be possible; the options then are to either laparotomize and approach the aorta-iliac segment or to perform an extraperitoneal approach to the external iliac (the author’s favored technique). This can be performed reasonably swiftly and does not affect gut function in the same way a laparotomy would. An oblique iliac fossa incision is made four finger widths above the inguinal lig- ament (Figure B-3); the external oblique aponeurosis is split in the line of the fibers and the underlying muscle split to reveal the peritoneum (Figure B-4). The peritoneum is full of the gut and is gently shifted upward to reveal the external iliac vessels, which can then be controlled.
While more technically difficult then a laparotomy, this technique has the advantage of allowing speedy access and good recovery of gut function.
B. Vascular Injuries in the Groin 577
Figure B-1. False femoral aneurysm.
Figure B-2. Direct approach to femoral vessels.
578 D.J. Williams
Figure B-3. Skin incision, iliac approach.
Figure B-4. Division of muscles.
