How to perform a external iliac artery exposure

Skin Incision and Advancing to Fascia

1. The incision is made with a scalpel according to the planned line to the subcutaneous fat level.

2. The subcutaneous tissue is divided with a scalpel or electrocautery to the external oblique fascia level.

3. The anterior superior iliac spine should be palpated to confirm proper positioning close to it to ensure the dissection avoids inadvertent opening of the peritoneum.

4. When the fascia level is reached, a retractor is positioned.

5. The fascia and the obliquely oriented fibers of the external oblique aponeurosis should be visible throughout the wound length.

Advancing Through the Abdominal Wall Layers

1. The external oblique fascia and aponeurosis are incised with scissors along the line of the fibers.

2. The fascia and aponeurosis are divided to the full length of the incision, exposing the underlying muscle tissue.

3. The abdominal wall muscles are split bluntly in line with their fiber direction, taking care not to injure the abdominal wall nerves running between the layers.

4. The abdominal wall layers are passed through when extraperitoneal fat is encountered.

5. The medial extent of the muscle layer is carefully divided to match the original incision length toward the inguinal ligament's midpoint.

6. After the muscles are passed through, the retractor is positioned deeper in the wound.

Locating and Controlling the External Iliac Artery

1. Fingers are used to dissect carefully through the extraperitoneal fat to locate the external iliac artery. The peritoneum lies cranially and can be gently moved aside.

2. If the arterial pulse is not palpable, the psoas muscle can serve as a landmark, as the external iliac artery runs along its medial border.
   Palpation toward the inguinal ligament can also help identify the artery as it passes beneath this structure, transitioning to the common femoral artery.

3. As the retractor positioning is optimized deeper, the distal part of the external iliac artery is visualized passing under the inguinal ligament, with the proximal segment diving deeper into the pelvic cavity.

4. Once identified, the artery is carefully encircled with an instrument to allow placement of a vessel loop for vascular control.

5. The loop is passed twice around the artery, achieving the intended proximal control.

Review of Exposed Anatomy

1. The inguinal ligament marks the transition from the external iliac to the common femoral artery. It is typically preserved, but can be divided if additional exposure is required, with subsequent repair during closure.

2. The inguinal ligament is exposed here for demonstration, revealing its structure as the thickened, folded inferior border of the external oblique aponeurosis encountered previously.
   It serves as the anatomical boundary between the abdominal cavity and the thigh.

3. Vascular loops (A-D) are placed both for proximal and distal control. Exposure to this extent is rarely required in clinical practice, and vascular control can typically be achieved with a more limited approach.
   A) External iliac artery
   B) Common femoral artery
   C) Deep femoral artery
   D) Superficial femoral artery

4. The external iliac artery can be followed further into the pelvic cavity if needed, but it requires careful dissection. This approach is adequate for proximal vascular control, but the exposure of deeper pelvic structures is inherently limited. Extensive iliac vessel exposure typically requires laparotomy.
   Deeper within the pelvis are multiple nerve structures to watch out for and the ureter, which crosses the iliac vessels proximally.

5. The external iliac vein courses alongside the artery and at the level of the inguinal ligament transitions to the femoral vein.

6. The inferior epigastric artery branch arises from the common femoral artery at the level of the inguinal ligament.

7. The deep femoral artery branches out proximally, such as the femoral circumflex arteries, supplying the surrounding thigh structures.

8. The superficial femoral artery provides the main arterial supply to the distal lower extremity and must be preserved to maintain limb viability.

Closure

1. The muscle layers are approximated loosely. Here, a single figure-of-eight suture is applied.

2. The external oblique aponeurosis fascia is closed securely, in this case using a continuous technique with non-absorbable suture with bites placed approximately 1 centimeter apart.
   The goal is to achieve a snug but not overly tight closure of this layer.

3. The subcutaneous layer and skin are closed in standard fashion. The closure of the femoral wound is done in layers and described in detail in the femoral artery exposure procedure.