We performed the first abdominoinguinal incision on March 16, 1979 (Fig. 41.1). It was several months later, after the performance of a few similar cases, that we realized that despite the specificities of the individual operations arising from the specificities of the individual tumors and patients, there was a common structure in the sequence and aim of the operative steps, which was the in continuity exposure of the lateral pelvis (and by extension, of the peritoneal cavity) to the involved groin. The need for in continuity exposure was predicated by the need to preserve the vascular supply of the ipsilateral lower extremity while a satisfactory margin was attained around the tumor. By the time of publication of the Atlas of Operations for Soft Tissue Tumors, in 1985 [1], we had performed 22 cases with the abdominoinguinal incision, and by October 2012 about 150 such operations. In the following, the main features of this incision are presented with each operation described along with the more common deviations from the basic technique, in order to counter specific circumstances.

An incision starting in the midline a few centimeters or more above the umbilicus, depending on the proximal extent of the tumor, is carried around the umbilicus on the same side as the tumor and then along the midline all the way down to the pubic symphysis (Fig. 41.2). The linea alba is incised, followed by the peritoneum, allowing exposure of the medial surface of the tumor mass and exploration of the abdomen to search for evidence of metastatic disease to the liver or other sites (Fig. 41.3). Some preliminary dissection may be carried out between the tumor and adjacent loops of small or large bowel. The lower end of the peritoneal incision is continued around the bladder toward the obturator foramen. The skin incision then is extended from the pubic symphysis transversely to the mid-inguinal point on the same side, and then vertically in the femoral triangle for several centimeters, enough to allow exposure of the femoral vessels. The femoral artery and vein are exposed (Fig. 41.4). If exposure of the femoral vein is required further down, one may have to ligate and divide the great saphenous vein at the level of its entry into the femoral vein. The femoral artery is exposed, as well as the femoral nerve, which is found lateral and at a plane posterior to the artery. The rectus abdominis sheath and muscle are divided off the pubic crest (Fig. 41.5).

Although the initial steps of the abdominoinguinal incision are shown above with a large mass in the right iliac fossa, subsequent steps are shown with in continuity dissection of larger inguinal, iliac and obturator nodes which allows a clearer view of the sequential steps of this procedure compared to the dissection of a large mass in the same area.

In the case of large retroperitoneal lymph nodes from melanoma or other tumor, which may start in the groin but extend into the external iliac nodal chain—lymph nodes of such size that they cannot be removed through the usual incision for the radical groin dissection—one may use the abdominoinguinal incision. In these patients, the part of the incision that extends into the groin is made longer, to the apex of the femoral triangle, and flaps are developed medially to the medial edge of the adductor longus and laterally to the lateral edge of the sartorius. The inguinal nodes are dissected off the surface of the femoral artery and vein. If dissection of the deep nodes (obturator, iliac) is done through this incision, the lymph nodes in the inguinal area are mobilized and left to be removed in continuity with the lymphatic tissue of the femoral canal and the deep nodes (Fig. 41.6). The inguinal ligament is lifted after it is divided at the pubic tubercle, and the inferior epigastric vein and artery are ligated and divided serially (Fig. 41.7). The lateral third of the inguinal ligament, which is fused with the iliac fascia, is separated from the fascia with care to avoid the deep iliac circumflex artery and vein, which course along the underside of the inguinal ligament in a sheath provided by the edge of the iliac fascia. For a tumor in the iliac fossa, these vessels must be ligated and divided medially as well as laterally. The retroperitoneal space is widely open after the inguinal ligament is separated off the iliac fascia in its lateral third; the inferior epigastric vessels have been divided, the inguinal ligament is detached off the pubic tubercle, and the anterior rectus sheath and muscle is divided off the pubic crest. There is now in continuity exposure of the lower abdominal aorta, inferior vena cava, common iliac vessels, external iliac vessels, and femoral vessels on the side of involvement. Any lymph nodes from the area of the obturator fossa are mobilized, exposing the obturator nerve posteriorly (Fig. 41.8). The lymph nodes are dissected off the iliac vessels all the way to the bifurcation of the aorta, and at a higher level if necessary. The ureter is exposed as it courses over the bifurcation of the common iliac vessels, and the specimen is removed after some medial attachments to the adipose tissue around the urinary bladder are divided (Fig. 41.9). In a woman, there is no problem in dividing the anterior rectus sheath and the rectus abdominis muscle off the pubic crest and then continuing to divide the inguinal ligament off the pubic tubercle. In men, however, the spermatic cord is in front of the pubic tubercle in its way to the subcutaneous (superficial) inguinal ring and through the inguinal canal to the internal ring. Therefore, the incision from the superficial inguinal ring is extended in the direction of the fibers of the external oblique aponeurosis for a few centimeters in order to expose the spermatic cord (Fig. 41.10). Then, as the spermatic cord is retracted, the transversalis fascia is incised on the posterior wall of the inguinal canal all the way to the internal inguinal ring (Fig. 41.11), being careful of the inferior epigastric vessels, which course on the medial side of the internal ring and therefore must be ligated and divided. This procedure allows medial displacement of the spermatic cord and preservation of the ipsilateral testicle. The alternative is to divide the inguinal floor from inside, following the division of the anterior rectus sheath and rectus abdominis off the pubic crest and then of the inguinal ligament off the pubic tubercle. In other words, one can expose and incise from inside the transversalis fascia, which forms the inguinal floor, again allowing the medial extrication of the spermatic cord and preservation of the blood supply to the testicle. Deep to the internal inguinal ring, the spermatic cord bifurcates as it separates into its two main components, the vas deferens, which follows a medial direction to the spermatic vesicles, and the internal spermatic artery and vein, which follow a cephalad, slightly medially inclined direction toward their communication with the aorta and inferior vena cava. The internal spermatic artery and vein may be ligated and divided in the retroperitoneal space without affecting the viability of the ipsilateral testicle. Indeed, the spermatic cord also may be divided in the inguinal canal while the viability of the ipsilateral testicle is preserved, as long as one does not separate the testicle off the scrotal skin, from which it receives small blood vessels that are capable of hypertrophy to carry an adequate blood supply to maintain its viability, although some atrophy may occur. After the exposure provided through the abdominoinguinal incision, the resection of the tumor mass with adjacent organs or the dissection of nodes is completed.