Ilioinguinal Approach to Acetabulum

The ilioinguinal approach to acetabulum allows exposure of the inner surface of the pelvis from the sacroiliac joint to the pubic symphysis. It allows visualization of the anterior and medial surfaces of the acetabulum, it’s suitable for exposure of anterior column fractures of the acetabulum.

The ilioinguinal approach to acetabulum is used for:

  1. Anterior wall fractures.
  2. Anterior column fractures.
  3. Anterior column plus posterior hemi-tranverse fractures.
  4. Majority of associated both-column fractures:
    • Even in presence of posterior wall fracture.
    • Posterior-wall fragment attached to ilium can be reduced through lateral ilium exposure.
    • Not recommended for fractures associated with comminuted post wall fractures or SI joint fractures.
  5. Some T-type:
    • Can be used for minimally posteriorly displaced T-type fractures.
  6. Some transverse fractures type.
  7. For transverse fractures if displacement is anterior.

  • Place the patient supine on the operating table  with greater troch on side of fracture at edge of table.
  • Place bump under ipsilateral buttock.
  • Flex affected leg to relax iliopsoas and neurovascular structures.

  • Landmarks:
    1. The anterior superior iliac spine.
    2. Pubic Tubercles.
  • Incision:
    • Incision begins at midline 3-4cm proximal to symphysis pubis,
    • Proceeds laterally to tThe anterior superior iliac spine, then along anterior 2/3’s of iliac crest,
    • Extend incision beyond most convex portion of ilium.

  • There is no true internervous plane for the The ilioinguinal approach to acetabulum.
  • The dissection consists essentially of lifting off muscular, nervous, and vascular structures from the inner wall of the pelvis.

  • Dissect through subcutaneous fat.
  • Start laterally, incise periosteum along iliac crest,
  • Release abdominal and iliacus muscle insertions from ilium,
  • Subperiosteally elevate iliacus from internal iliac fossa to SI joint and pelvic brim,
  • Pack internal iliac fossa for hemostasis,
  • Through lower portion of incision expose aponeurosis of external oblique and rectus abdominus muslces,
  • Divide exposed aponeurosis in line with skin incision one cm proximal to external inguinal ring:
    • will often have to sacrifice lateral cutaneous nerve of the thigh,
  • Thus unroofs inguinal canal, and exposes inguinal ligament:
    • identify and protect ilioinguinal nerve.
  • Isolate spermatic cord/round ligament and place penrose around structures to retract.
  • Sharply incise inguinal ligament, leaving 1-2mm cuff of ligament still attached to divided origin of internal oblique, transversus abdominus, and transversalis fascia.
  • May need to divide conjoint tendon at its insertion on pubis as well as anterior rectus sheath.

  • Bluntly dissect a plane between the symphysis pubis and the bladder (space of Retzius), pack with sponges,
  • Expose anterior aspect of femoral vessels and surrounding lymphatics in midportion of incision (lacuna vasorum):
    • Lacuna musculorum is lateral and contains iliopsoas, femoral nerve, and lateral femoral cutaneous nerve.
  • Identify iliopectineal fascia, which separates the lacuna vasorum and lacuna musculorum.
  • Dissect vessels and lymphatics from medial aspect of fascia, free iliopsoas and femoral nerve from lateral aspcet of fascia.
  • Sharply divide iliopectineal fascia down to pectineal eminence, then detach from pelvic brim; allows access to true pelvis, quadrilateral plate, and posterior column.
  • Place second penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve.
  • Place thrid penrose drain around femoral vessels and lymphatics.
  • Identify and ligate corona mortise before retracting vessels.
  • Subperiosteal dissection is used to expose pelvic brim, rami, and quadrilateral surface.
  • Work through 3 windows to reduce and fix fracture:
    • Medial window:
      • Medial to external iliac artery and vein.
      • Access to pubic rami; indirect access to internal iliac fossa and anterior SI joint.
    • Middle window:
      • Between external iliac vessels and the iliopsosas muscle.
      • Access to pelvic brim, quadrilateral plate, and a portion of the superior pubic ramus.
    • Lateral window:
      • Lateral to iliopsoas (iliopectineal fascia).
      • Access to quadrilateral plate, SI joint, and iliac wing.

  • Proximal Extension:
    • The ilioinguinal approach to acetabulum can be extended proximally to expose the sacroiliac joint.
    • Extend the skin incision posteriorly, following the iliac crest.
    • Using sharp dissection, cut down onto the bone.
    • Then strip off the origins of the iliacus from the inside of the ilium using blunt dissection.
    • Retract this iliacus medially to expose the inner wall of the ilium and the sacroiliac joint.
  • Distal Extension:
    • Ilioinguinal approach to acetabulum cannot be extended distally.

The structures at risk during ilioinguinal approach to acetabulum includes:

  1. Femoral nerve.
  2. Femoral and External Iliac Arteries:
    • Damage can cause thrombosis.
    • Protect them by leaving in femoral sheath.
  3. Lymphatics:
    • Present in fatty areolar tissue around vessels.
    • Disruption can impair postoperative lymphatic drainage and cause edema.
  4. Lateral cutaneous nerve of thigh:
    • Often have to sacrifice leaving numbness on the outer side of the thigh.
  5. Inferior epigastic artery:
    • Must sacrifice if has anomoulous origin off obturator artery to allow retraction of iliac vessels.
  6. Spermatic cord (contains vas deferens and testicular artery):
    • Must be protected.
    • Damage can cause testicular ischemia, infertility.
  7. Heterotopic Ossification:
    • Much more common in the extended iliofemoral and Kocher-Lagenbeck approaches.
  8. Obturator nerve:
    • Causes medial thigh numbness when injured.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
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Images Source:
  • Surgical Exposures in Orthopaedics 4th Edition Book.

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