Abdominoinguinal Incision in the Resection of Pelvic Tumors and Limb Salvage

Some primary tumors in the pelvis (usually soft tissue sarcomas) extend to the greater pelvis with lateral extension often to one of the iliac fossae, distending the lower abdominal wall forward and reaching all the way to the level of the umbilicus or higher. Similarly, tumors arising in the mid abdomen, as they grow, may descend and adhere to the walls of the pelvis creating difficulty for the surgeon to come around their distal surface for control of the major vessels (external iliac). These tumors often have been called unresectable because the surgeon cannot achieve distal exposure, and therefore is unable to perform a dissection between the distal portion of the tumor and the external iliac or femoral vessels, or an en bloc resection of the tumor with the iliofemoral vessels. The external iliac and femoral vessels are referred to as distinct entities in anatomical texts, because the lower musculoaponeurotic layers of the anterior abdominal wall and the inguinal ligament conceal the former when the groin is opened, and the intact groin conceals the latter when the lower abdomen is opened. The abdominoinguinal incision imposed by the needs of exposure for the dissection of tumors in this area shows the iliac and femoral vessels in their continuity and functional unity, suggesting the term iliofemoral vessels as expressive of this unity when surgically considered in the resection of tumors in their vicinity. A midline abdominal incision cannot expose the iliac or femoral vessels distally, so the surgeon cannot combine the exposure of the lower abdominal aorta, common iliac vessels, with the distal external iliac and femoral vessels on the same side in continuity. In the past patients with tumor presenting with unilateral fixation to the wall of the pelvis, external iliac vessels, and iliac fossa were offered and often were treated with hemipelvectomy. Actually, the tumor in the pelvis may extend to both sides, so it may be necessary to expose the external iliac and femoral vessels on both sides in continuity with the common iliac vessels and the lower abdominal aorta. Because the iliopsoas inserts in the lesser trochanter, sarcomas located in the area of the iliac fossa may extend behind the inguinal ligament into the groin and thus present difficulty in their exposure through an abdominal or flank incision, neither of which provides in continuity exposure of the groin. Tumors also may adhere to or invade the external iliac vessels. If this occurs all the way down to the inguinal ligament, their resection is difficult because the usual incisions cannot expose simultaneously in one field the lower abdominal aorta–inferior vena cava and the common iliac, external iliac, and femoral vessels on one or both sides. Soft tissue or other tumors with fixation to the lateral wall of the lesser pelvis also present difficulty in resection and often are called unresectable because a midline incision cannot give adequate exposure of the obturator foramen and the external iliac vessels down to the level of the inferior epigastric vessels. Furthermore, some tumors that are in the lesser pelvis adhering to the pelvic wall also infiltrate the ipsilateral pubic bone and extend through the obturator foramen to involve the adductor group of muscles. Tumors in these locations have often been called unresectable, or they have been resected via a hemipelvectomy of the ipsilateral extremity.