Pirogov's Incision

PIROGOV'S INCISION, external laparotomy, laparotomia externa. This incision was first described by N. I. Pirogov in his Surgical Anatomy of Arterial Trunks and Fasciae and was developed by him for the extraperitoneal approach to the external iliac artery (arteria iliaca externa) for the purpose of its ligation. The incision was given the inappropriate, although quite widely distributed, name of external laparotomy (laparotomia externa). To perform the incision, it is first of all necessary to palpate Poupart's ligament well, which is easily achieved in a non-obese person upon strong extension of the hip joint; in obese people, one must be guided by the inguinal fold. The skin incision is made parallel to Poupart's ligament, 1-2 cm above it, and its end is 4-5 cm (slightly less than 3 finger breadths) from the pubic tubercle (tuberculum pubicum); the incision is made for a length of 8-9 cm so that its middle corresponds to the projection of the external iliac artery; the latter is projected from the midpoint of the distance between the anterior superior spine and the pubic symphysis in the direction of the umbilicus. The incision penetrates through the skin, subcutaneous tissue with the superficial fascia until the gleaming silvery aponeurosis of the external oblique abdominal muscle (musculus obliquus abdominis externus) is exposed. The vessels lying in the subcutaneous tissue (arteria et vena epigastricae superficiales) are severed between ligatures. The aponeurosis is incised along the course of the fibers immediately above Poupart's ligament. The edges of the wound are retracted with blunt hooks; the muscle fibers of the lower edge of the internal oblique and transverse abdominal muscles appear; they are bluntly isolated from the groove of Poupart's ligament and retracted slightly upward with a hook; after which the transversalis fascia

of the abdomen (fascia transversalis) opens; it is white-yellowish in color, tightly stretched (Pirogov). The fascia is incised on a grooved probe; behind it, the loose tissue is exposed, filling the space between the peritoneum arching backward from the anterior abdominal wall and Poupart's ligament; the tissue is bluntly separated with anatomical forceps; in the depths of the wound, the smooth inner edge of the iliopsoas muscle (musculus iliopsoas), covered by the iliac fascia (fascia iliaca), is felt, and upon it the pulsating external iliac artery (see figure). The possibility of damaging the peritoneum with careful separation of the tissue is almost excluded. When ligating the external iliac artery, it must be remembered that immediately above Poupart's ligament in front of the artery and across it runs the deep circumflex iliac vein (vena circumflexa ilii profunda);

Pirogov's incision during ligation of the external iliac artery: 1 - arteria epigastrica superficialis; 2 - peritoneum; 3 - fascia iliaca.

the latter is retracted downward. Approximately 7 mm above Poupart's ligament, and sometimes lower (Pirogov), approaching the place of origin of the deep circumflex iliac artery (arteria circumflexa ilii profunda), right at the ligament or behind it lies the origin of the inferior epigastric artery (arteria epigastrica inferior). The ligature on the external iliac artery should be applied above (proximally) these two arteries.