Obturator Bypass: A Classic Approach for the Treatment of Contemporary Groin Infection

Abstract

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.