Name:
14 Femoral Vessels
Description:
14 Femoral Vessels
Thumbnail URL:
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Duration:
T00H07M20S
Embed URL:
https://stream.cadmore.media/player/1729f62b-1706-4cc5-9665-55616cb5435d
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/1729f62b-1706-4cc5-9665-55616cb5435d/1420Femoral20Vessels.mov?sv=2019-02-02&sr=c&sig=VkZHR6ZeGKrXprSPyzK0HkRMwgcXB0WRKJULvjV7vvc%3D&st=2025-03-14T06%3A29%3A19Z&se=2025-03-14T08%3A34%3A19Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will be discussing the exposure of the femoral vessels.
Segment:1 Objectives.
We will start by discussing the relevant anatomy, instruments and positioning, the techniques and exposure, and finally, the tips and pitfalls of this exposure.
Segment:2 Anatomy.
The common femoral artery is the continuation of the external iliac artery after crossing under the inguinal ligament and entering the femoral triangle.
The borders of the femoral triangle are the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. As the femoral vessels travel distally, the superficial femoral vessels enter Hunter's, or the adductor canal-- which is bounded by the muscles of the medial and posterior thigh-- making exposure within Hunter's canal challenging as the bounding muscles will need to be incised in order to gain exposure of this segment of the superficial femoral vessels.
At the level just above the knee, the vessels exit the adductor hiatus and become the popliteal vessels. The lateral border of the femoral triangle is the sartorius muscle. This muscle may be utilized for tissue coverage of vascular reconstructions within the femoral triangle by mobilizing it, dividing it at its insertion, and suturing it to the inguinal ligament.
Medial to the sartorius muscle, the femoral nerve is encountered. Medial to the nerve, lies the common femoral artery. The common femoral artery also bifurcates in this region to the profunda femoral artery, which dives deep into the thigh, and the superficial femoral artery, which continues distally to provide blood flow to the leg. The most medial structure in the femoral triangle is the common femoral vein.
Segment:3 Instrumentation and Positioning.
The patient should be positioned supine with the hip and knee slightly flexed and externally rotated to give access to the medial thigh.
The prep should extend from the umbilicus, including bilateral groins, and circumferentially to the foot of the affected leg and the contralateral leg to the level of the knee, in case a saphenous vein graft is required. Instruments should include a standard vascular tray, a selection of vascular conduits and shunt materials, as well as Fogarty catheters, and heparin. The external landmark for the location of the femoral vessels in the groin is the inguinal ligament, which is located between the anterior iliac spine and the pubis symphysis.
The incision is made in the skin approximately two centimeters below the inguinal ligament, at its midpoint, in a longitudinal fashion. Note that this incision is preferred over a horizontal or oblique incision for its extensile potential, or should more distal or proximal exposure be required. The length of the incision should be determined by the nature and location of the injury. As the incision is carried through the subcutaneous fat, note that there are numerous lymphatics which may be encountered.
If possible, these should be ligated and divided in order to prevent possible, future wound complications. Deep to the subcutaneous fat, the fascia is encountered and incised, and the femoral sheath is then encountered and similarly incised, exposing the underlying common femoral artery. The common femoral artery is then carefully dissected along its anterior surface in order to prevent avulsion of any branches.
The medial border of the common femoral artery is then carefully dissected in order to expose the border of the common femoral vein. The common femoral vein is then similarly dissected along its anterior surface in order to prevent avulsion of any branches and inadvertent bleeding. A vessel loop is then used to encircle the common femoral artery, which can then be used in retraction during dissection of the artery, and may also be double-looped for vascular control.
Similarly, the common femoral vein is encircled using a vessel loop. Dissection of the common femoral artery is continued distally, and the bifurcation is identified. The profunda femoris artery is identified in the posterolateral position and carefully dissected and encircled using a vessel loop.
Next, a vessel loop is used to encircle the superficial femoral artery. The femoral nerve may be identified lateral to the common femoral artery and is encircled here, using a yellow vessel loop. The sartorius muscle is the lateral border of the femoral triangle and may be dissected and mobilized for soft tissue coverage of vascular reconstructions in this region, if necessary.
If the injury requires more proximal exposure, the incision may be extended proximally, and the inguinal ligament divided, in order to gain access to the distal external iliac vessels. If more distal exposure is required, recall that, in order to gain access to the femoral vessels in the adductor canal, the musculature on the posterior medial thigh will need to be incised.
Segment:4 Tips and Pitfalls.
If the femoral pulse is not able to be palpated, recall that the location of the femoral vessels in the groin is approximately two centimeters below the inguinal ligament, at its midpoint.
If the femoral vein is unable to be repaired due to patient extremis or injury greater than 50%, it may be ligated. The profunda femoris artery may be ligated if unable to be repaired with little immediate sequela. Arterial reconstructions above the knee may be performed using a prosthetic graft if saphenous vein is not available. In a damage control situation, always consider the need for a temporary shunt with delayed reconstruction.
And finally, while routine fasciotomies are not necessary with vascular reconstructions in this region, one should always consider the need for them and carefully monitor postoperatively for the development of compartment syndrome. Thank you.
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