Incision medial aspect of calf along inferior border of the tibia extending up towards the new and above the border of gastrocnemius
Divide Sartorius and gracilis as required to optimize exposure
Vein exposed first, lifting away to expose artery
By dividing soleus muscle along its attachement to the medial border of the tibia it is possible to expose the origin of ATA and whiole extent of TP trunk
If required divide entire medial head of gastrocnemius (can be left divided)
Fossa/entire length
Use posterior approach
Prone
Lazy S incision medial proximally to lateral distally through popliteal fossa
Deepen incision through fascia and fat pad defining the diamond between hamstring
muscles above and two heads of gastrocnemius below
Artery will be deepest
Subclavian
Transverse incision 1cm above medial third of clavicle
Divide platysma
Divide clavicular head of SCM
Dissect and retract fat pad containing scalene lymph nodes
Identify phrenic nerve which passes obliquely from lateral to medial across the front anterior scalene to lie along the medial border of its tendon and usually separated from it by a few mm
Retract this medial
Retract scalenus anterior around its tendon to protect the phrenic nerve and divide the muscle
Extended exposure can be obtained by excision of the inner 2/3rds of the clavicle though rarely required
If need proximal access use a median sternotomy or left lateral thoracotomy
Axillary
Horizontal incision 1cm below lateral third of clavicle
Split fibres of Pectoralis major
Divide tendon of pectoralis minor from acromion process
Find axillary artery surrounded by cords of brachial plexus
Brachial Artery
Proximal
Groove between biceps and brachialis on inner aspect of the upper arm
Still enclosed by cords of plexus joining to form median nerve
Median nerve crosses it obliquely from lateral to medial side
Distal
Lazy S incision in antecubital fossa from medial to lateral (distally)
Divide biceps aponeuorosis
Distal extension of this incision permits radial, ulnar and anterior interosseous arteries to be followed
Relative anatomy
Femoral
Surface marking is midinguinal point, halfway between ASIS and pubic symphysis o CFA is related anatomically to the inguinal ligament rather than the groin crease
which can be 2-3cm distal to the CFA in a more obese patient
Popliteal
The popliteal fossa is diamond shaped, with four borders. These borders are formed by the muscles in the posterior compartment of the leg and thigh:
Superomedial border: Semimembranosus
Superolateral border: Biceps femoris
Inferomedial border: Medial head of the gastrocnemius.
Inferolateral border: Lateral head of the gastrocnemius and plantaris
The popliteal fossa also has a floor and a roof:
Floor formed by the posterior surface of the knee joint capsule, and by the
posterior surface of the femur
Roof made of up two layers; popliteal fascia and skin.
The popliteal fascia is continuous with the fascia lata of the leg
Contents from medial to lateral
Popliteal artery
Popliteal vein
Tibial nerve
Common fibular nerve
Subclavian
Retraction of Scalenus Anterior exposes SCA and vertebral, internal thoracic, and
thryocervical branches
The first thoracic nerve root and lower trunk of brachial plexus cross the first rib
above and posterolateral to artery
Subclavian vein is deep to clavicle and not normally seen
On left the thoracic duct enters the confluence of the internal jugular and subclavian veins