Place the patient supine on the operating table with the thigh mildly externally rotated, flexed, and elevated at the level of the knee joint. Palpate the inguinal ligament and identify the pubic tubercle and anterosuperior iliac spine. Place a longitudinal skin incision centered over the femoral artery (Fig. 108.1A). This skin incision should extend from 1 to 2 cm above the inguinal ligament to about 10 cm below the inguinal ligament. The profunda femoris artery usually takes off from the common femoral artery at the level of the inguinal ligament or about 1 to 3 cm distal to it. The skin incision must, therefore, extend above the inguinal ligament to expose the common femoral artery adequately. If the incision or dissection is below the usual anatomic bifurcation of the common femoral artery, only the superficial femoral artery will be seen.

Several lymph nodes will be found anterior to the femoral artery in the femoral canal (Fig. 108.1B). Be careful to avoid injury to the lymphatic channels and lymph nodes in this area. Disruption of the lymphatic system can result in lymphorrhea, lymphocele formation, or wound problems. Dissect the common femoral, profunda femoris, and superficial femoral arteries gently. A small venous branch courses over the profunda femoris artery. Ligate and divide this vein to allow access to the profunda femoris distal to its first perforating branch. Obtain proximal control of the common femoral artery and distal control of both the superficial femoral and profunda femoris arteries using Silastic loops.

The greater saphenous vein is superficial and medial to the common femoral artery. The groin incision diagrammed allows for excellent exposure of the saphenous vein. Either continuous or interrupted skin incisions may be used to perform an in situ bypass.