CHAPTER

90
Abdominoinguinal
Incision for Resection of
Pelvic Tumors
Tristan D. Yan, BSc(Med), MBBS, MS, MD, PhD,
and Paul H. Sugarbaker, MD, FACS, FRCS

◆ Pelvic tumors with lateral fixation present difficulties in their resection, primarily because of inadequate
exposure through conventional abdominal incisions. The difficulty arises with tumors in the lower part
of the pelvis where the anterior abdominal wall converges with the retroperitoneal structures. In this
area, the inguinal ligament spanning between the anterior superior iliac spine and the pubic tubercle
provides an obstacle to unhindered exposure. A midline, paramedian, or oblique abdominal incision
usually does not provide adequate exposure for safe resection of these tumors. Traditional incisions
provide enough exposure for the dissection and control of the common iliac vessels proximally, below
the bifurcation of the aorta, but do not afford exposure of the terminal portion of the external iliac
vessels because the tumor mass hinders further visibility. Often these tumors are considered
unresectable.
◆ Karakousis has described a solution for these problems with exposure. What is needed for the resec-
tion of these tumors is an incision that simultaneously provides an in-continuity exposure of the
abdominal cavity and one or both groins so iliac and femoral vessels are exposed in one field. For this
incision, both an abdominal component and an in-continuity inguinal component are needed—that
is, an abdominoinguinal incision. The inguinal ligament may have to be divided to allow uninterrupted
exposure and control of the iliofemoral vessels. A transverse incision connecting with the midline
incision, by dividing the origin of the rectus abdominis from the pubic crest and the insertion of the
inguinal ligament to the pubic tubercle, provides the necessary link that allows a single in-continuity
field and optimizes exposure.
◆ In practice there are variations of this incision, depending on the location, size, and complexity of the
pelvic sidewall tumor. The abdominoinguinal incision may function much in the same way that the
thoracoabdominal incision is used for the upper quadrant of the abdomen.

I. SPECIAL PREOPERATIVE PREPARATION

◆ The indications for the abdominoinguinal incision are: (1) abdominal or pelvic tumors extending over
the iliac vessels, (2) tumors in the iliac fossa (Fig. 90-1), (3) primary tumors possibly involving the
iliac vessels or large iliac lymph node metastases, (4) tumors with fixation to the wall of the true pelvis
or large obturator nodes, (5) tumors involving the pubic bone with or without extension to the pelvis
or adductor group of muscles, and (6) tumors of the groin when involving the vessels or the lower
abdominal wall or extending into the retroperitoneal area.
◆ A computed tomography scan of the abdomen and pelvis provides an assessment of the extent of the
pelvic tumor (see Fig. 90-1), its relationship with the iliac vessels and femoral nerve, and whether
there is invasion of the iliac bone.

II. OPERATIVE TECHNIQUE

Position
◆ The patient should be placed in the supine position.

686
 Chapter 90 • Abdominoinguinal Incision for Resection of Pelvic Tumors 687

Incision

Abdominal Incision
◆ A midline abdominal incision is made from above the umbilicus to the pubic symphysis (Fig. 90-2).

The peritoneal cavity is entered and explored to assess the extent of disease. Preliminary dissection
between the tumor mass and common iliac vessels may be performed. Involvement of the common
iliac vessels does not necessarily mean they cannot be resected, because they can be removed en bloc
with the tumor. When there is a question of involvement of the iliac vessels distally, the common iliac
vessels are dissected free, and vessel loops are passed around them.

Inguinal Incision
◆ If the decision is made to proceed with the resection, the lower end of the midline abdominal incision

is extended transversely either along the inguinal ligament (Fig. 90-3) or to the midinguinal point and
then vertically, over the course of the femoral vessels, for a few centimeters.

Figure 90-1. A tumor mass is situated in the right iliac fossa invading the
iliacus muscle and immediately adjacent to the femoral nerve and external Figure 90-2. A midline abdominal incision is made from
iliac vessels. above the umbilicus to the pubic symphysis.

1
Small
intestines

A B
Figure 90-3. An inguinal incision is made by extending the lower end of the midline abdominal incision trans-
versely along the inguinal ligament. The transverse portion of the incision is deepened to the surface of the anterior
rectus sheath, which is divided. The rectus abdominis muscle is transected a few millimeters from its origin on the pubic
crest. The dissection is viewed from the left side of the patient.
688 Section XVI • Soft Tissue/Bone Resection
◆ The transverse portion of the incision is deepened to the surface of the anterior rectus sheath, which
is divided, and the rectus abdominis muscle is transected a few millimeters from its origin on the pubic
crest. This incision is through its tendinous portion. At the same time, the inferior deep epigastric
arteries and veins are ligated and divided (Fig. 90-4).

Main Dissection
◆ The selection of the incision either parallel to or across the inguinal ligament is dependent on the
location of the tumor. In many situations in which the tumor is large and distal and pressing against
the obturator foramen (foramina) or the obturator areas, one can obtain sufficient exposure with a
unilateral or bilateral use of the transverse portion of the full incision. In other words, the lower end
of the midline incision is extended transversely from the pubic symphysis to the pubic tubercle, and
the ipsilateral-rectus sheath and muscle are divided off the pubic crest.
◆ If the tumor is simply a pelvic mass extending over and obscuring the iliac vessels, the improved
exposure allows the dissection of the mass off the vessels and safe ligation of any tumor-feeding
branches (Fig. 90-5). For a tumor located in the iliac fossa, the incision is extended parallel to the
inguinal ligament.
◆ The femoral nerve is located lateral to the femoral artery, immediately posterior to the continuation of
the iliac fossa. Further cautious dissection along this nerve determines its relation to the tumor and
whether it can be saved (Fig. 90-6). With lateral retraction and elevation of the musculocutaneous

Figure 90-4. The inferior deep epigastric artery and vein are ligated in
continuity, then divided.
 Chapter 90 • Abdominoinguinal Incision for Resection of Pelvic Tumors 689
1 Gallbladder 8
Mobilized
ascending colon

2
Sarcoma in
iliac fossa

Psoas muscle 7
Ureter 6
External iliac artery 5
External iliac vein 4

Obturator nerve
3

Figure 90-5.

1
Sarcoma

Femoral nerve 2

Psoas muscle 3

External iliac artery

4
External iliac vein
5

Figure 90-6.
690 Section XVI • Soft Tissue/Bone Resection

flap, dissection of the tumor off the anterior abdominal wall is made possible. The tumor is removed
en bloc with adequate surgical margin (Fig. 90-7, A and B, and Fig. 90-8).

Closure
◆ The closure of the abdominoinguinal incision involves approximation of the rectus sheath and muscle
to their remnants on the pubic crest using nonabsorbable suture. Lateral to the vessels, the inguinal
ligament is approximated to the iliac fascia and medial to the vessels to the Cooper ligament. When a
defect in the fascia has been created, it may be covered with an allogeneic mesh, which also replaces
the inguinal ligament (Fig. 90-9). The midline abdominal incision is closed in continuity with the

Emptied right 1
iliac fossa

External iliac artery

2
External iliac vein 3
Spermatic cord 4

A
Figure 90-7.

External iliac artery graft 5

1
External iliac vein graft 2
6

B
 Chapter 90 • Abdominoinguinal Incision for Resection of Pelvic Tumors 691

Figure 90-8. Dissection of the tumor away from the anterior abdominal wall, wing of
the ilium, femoral nerve, and common and iliac artery allows en bloc resection with a
minimal surgical margin.

1
Defect covered by mesh

Figure 90-9.
692 Section XVI • Soft Tissue/Bone Resection

Figure 90-10. The midline abdominal incision is closed in continuity with

the inguinal incision. Suction drains are placed beneath the abdominal wall and
in the subcutaneous layer.

inguinal incision. A suction drain is placed in the subcutaneous layer (Fig. 90-10). The skin is closed
in a routine fashion.

III. ALTERNATIVE TECHNICAL APPROACHES (PRO/CON) AND PEARLS

◆ The abdominoinguinal incision has been used in patients with a variety of tumors, usually soft tissue
sarcomas. These tumors often present with fixation to the soft tissues of the wall of the pelvis and can
be resected with the abdominoinguinal incision. Some patients may require abdominobiinguinal inci-
sion, that is, bilateral extension of the midline incision to the groins. Tumors involving the innominate
bone, with the exception of the medial portion of the pubic bone, are best resected with the use of
techniques of internal hemipelvectomy and, if necessary, hemipelvectomy.
◆ The abdominoinguinal incision renders resectable the majority of pelvic tumors with lateral fixation to
the soft tissues of the pelvis and, through improvement in exposure, allows for a safe, deliberate dissec-
tion. It is the counterpart of the thoracoabdominal incision for the upper quadrants of the abdomen.
The results from the use of this incision obviously depend on the histologic type and stage of the tumor
and the expected margin of resection one can obtain. It should be used when appropriate and in the
context of the biology of the tumor, the expected margin, and the possible use of adjuvant treatments.

IV. SPECIAL POSTOPERATIVE CARE

◆ The abdominoinguinal incision heals well without complications. In the event of a previous transverse
incision in the lower quadrant, which may have interrupted the vascular connection to the superior
epigastric vessels and the distal portion of the intercostal and lumbar branches, a small area of necrosis
at the junction of the midline and transverse portions of the incision may occur because this incision
divides the inferior epigastric vessels. If a small area of necrosis develops, it is debrided and allowed
to heal by second intention.
◆ Early mobilization is encouraged, and prophylactic heparin is administered to prevent thromboembolism.
◆ Good pain control can be obtained with use of epidural and/or patient-controlled analgesia. In some
cases, intravenous ketorolac may be necessary to allow sparing of narcotic drugs.

SUGGESTED READINGS

Karakousis CP: The abdominoinguinal incision in limb salvage and resection of pelvic tumors, Cancer 54:2543–2548, 1984.
Karakousis CP: The abdominoinguinal incision: the equivalent of thoracoabdominal incision for the lower quadrants of the abdomen,
J Surg Oncol 69:249–257, 1998.