After induction of anesthesia, the patient is positioned supine with the leg externally rotated and the knee slightly flexed to improve medial exposure. In larger patients, placing a bump under the thigh may further facilitate exposure. Preoperative antibiotics are frequently given despite the procedure being a Class I (infection classification) case. Most wound complications
are related to skin flap necrosis and lymphedema. These are not likely to be influenced by antibiotics, and randomized controlled trials have questioned their efficacy in preventing wound complications. However, because of these high wound complication rates, it is reasonable to provide a short course of antibiotics directed toward common skin flora. A Foley catheter and sequential compression devices are typically used. Muscle paralysis should be minimized until the femoral nerve is clearly identified. The skin preparation and draping should include lower abdomen to knee with wide medial and lateral exposure.

The inferior aspect of the incision is placed directly over the femoral vessels and should extend inferiorly to the convergence of the sartorius and femoral vessels. The superior aspect of the incision may vary based on surgeon choice, patient body habitus, and anticipated proximal extent of the dissection. We prefer a lazy S–shaped incision from the anterosuperior iliac spine to the medial thigh with the middle portion overlying the bottom of the inguinal ligament. The abdominal pannus in large body habitus patients can be rotated medially and elevated superiorly to provide better visualization. An alternate straight vertical incision traversing the inguinal ligament onto the lower abdomen works well in thin patients. If a previous sentinel lymph node biopsy site exists, it should be included in the incision. The proximal extent of the incision can vary depending on proximal extent of the dissection and will need to be longer if a deep dissection is to be done. The abdomino-inguinal incision is seldom indicated to gain wider access to the pelvis but can provide wide exposure of the entire internal pelvis when clinically indicated: proximal control of vessels, difficult bleeding, or bulky adenopathy.