Victor M. Sandoval, Matthew T. Allemang and Vikram S. Kashyap

Introduction

This chapter discusses the significance of groin anatomy for both open surgical exposure and percutaneous vascular access. Within the groin area are the femoral artery, femoral vein, and femoral nerve. The two main branches of the common femoral artery are the superficial femoral and profunda femoris arteries. The venous tributary of significance is the great saphenous vein, which joins the femoral vein in the fossa ovalis; this area is also called the saphenofemoral venous junction. Multiple venous branches are also present in this area. Vascular exposure is necessary for multiple procedures, including endarterctomy, embolectomy, bypass, and endovascular repair of aneurysms.

Femoral Anatomy

The femoral artery is an extension of the external iliac artery and by convention begins at the inguinal ligament. The first segment of the femoral artery and the femoral vein are enclosed within the femoral sheath and separated by a fiber septum (Fig. 36-1, A). The femoral sheath is a dense, fibrous band primarily consisting of two layers of fascia; the posterior aspect is a continuation of the fascia covering the pectineus muscle, and the anterior aspect is an extension of the transversalis fascia.

The iliac artery travels along the medial portion of the psoas muscle, then traverses the femoral triangle as the femoral artery. Moving laterally to medially within the femoral triangle are the femoral nerve, femoral artery, femoral vein, and the lymphatic tissue (NAVEL). The boundaries of the triangle are made up of the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus medially. The roof of the triangle is composed of skin, Camper’s fascia, the inguinal lymph nodes, and the fascia lata.

As the femoral artery moves obliquely over the pectineus muscle, it divides into two branches, the profunda femoris and superficial femoral (Fig. 36-1, B). The superficial femoral artery exits the femoral triangle into the subsartorial (Hunter’s) canal, crosses above the adductor longus muscle, and runs beneath the sartorius muscle (Fig. 36-1, C). As it moves distally, the superficial femoral artery decreases in caliber, eventually forming the popliteal artery.

Exposure of Femoral Artery

The most common approach allowing complete exposure of the common femoral artery and its branches is the vertical incision. The incision starts approximately at the midpoint of the inguinal ligament (Fig. 36-2, A). The patient is placed in the supine position. Location of the femoral pulse will guide the incision. Starting the incision directly over the pulse, 2 to 3 cm above the inguinal ligament, the surgeon continues the incision 4 to 8 cm distally toward the tip of the femoral triangle. In some cases, the patient’s pulse may not be palpable because of extensive calcification. If no pulse can be palpated, anatomic landmarks are identified: the pubic tubercle and anterior iliac spine (Fig. 36-2, B). The incision should be made at the midpoint between these two structures.

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