I770 



TTt^^TAN ANATOMY. 



Peritoneum and subserous tissue 

 Infundibuliform (transversalis fascia) 

 Internal oblique 



External oblique (intercolumnar fascia) 

 Superficial fascia and skin 



Deep epigastric, 

 artery 



usefulness as denoting' the route of the hernia, and are occasionally of value as land- 

 marks during herniotomies or operations for the radical cure of hernia. 



The sac of a complete oblique inguinal hernia (Fig. 1492) would carry with it 

 (i) a layer of extraperitoneal connective tissue ; (2) that portion of the transversalis 

 fascia known as the inftindibuliform fascia ; \2)) the muscular fibres derived from the 

 transversalis and internal oblique muscles, and called the cremaster viuscle ; (4) the 

 fibres from the external oblique aponeurosis that aid in strengthening the external 

 "ring," especially the upper angle, — the mtercohimnar fascia ; (5) the superficial 

 fascia^ — in the scrotum the dartos layer ; (6) the skin. 



The coverings of an incomplete oblique inguinal hernia will obviously depend 

 upon the point of its arrest, but such a hernia cannot be covered by either inter- 

 columnar fascia or dartos. 



The sac of a complete oblique inguinal hernia, if followed from within outv/ard, 

 would show first a puckered or pleated appearance at the mouth, due to the folds of 



peritoneum produced by 

 Fig. 1492. constriction ; next a portion 



narrow and elongated by 

 the pressure of the walls 

 of the canal, — the neck, — 

 which in such a hernia 

 would extend from the in- 

 ternal to the external ring ; 

 and finally a portion — the 

 fundus or body — which, re- 

 lieved from pressure, is usu- 

 ally irregularly ovoidal in 

 shape. 



The anatomical points 

 at which strangulation is 

 likely to occur are, in the 

 order of frequency, ( i ) the 

 edge of the internal ring, 

 (2) the edge of the exter- 

 nal ring, and (3) in the 

 canal (from fibres of the 

 transversalis or internal oblique), but the constriction of tne contents is not infre- 

 quently due to pathological changes in the neck of the sac itself. In operating to 

 relieve constriction at the internal ring, the relation of the epigastric artery should 

 be remembered. The in sion should be directly upward. 



Taxis. — In reducing — i.e., returning to the abdominal cavity — an oblique in- 

 guinal hernia, the shoulders and thorax should be raised to relax the abdominal 

 muscles ; the thigh fiexed and adducted to relax the fascia lata and external oblique 

 aponeurosis, and thus the margins of the external ring and the anterior wall — the most 

 unyielding — of the inguinal canal ; and the pelvis elevated so as to secure by the aid 

 of gravity a backward or upward pull on the contents of the hernia. After gentle 

 downward traction in the line of the canal so as to remove folds and lessen lateral 

 bulging of the sac and contents over the pillars of the external ring, and while 

 making pressure with the thumb and fingers of one hand at that point to prevent its 

 recurrence, the other hand encircles the fundus of the sac and with as evenly dis- 

 tributed force as possible makes pressure at first upward, then upward and outward, — 

 in the line of the canal, — and finally backward. 



Direct or internal inguinal hernia occurs in only 3-5 per cent, of cases. The 

 reasons for its relative infrequency have been given. To understand it, the region 

 internal to the deep epigastric artery should be examined (Fig. 1487). It has been 

 mentioned that this region has been subdivided by a fold corresponding to the plica 

 hypogastrica into a supravesical and an internal inguinal fossa (Fig. 1487). At the 

 inner angle of the former we find the abdominal wall strengthened {a) by the 

 presence of the rectus muscle, which extends outward as far as the pubic crest ; {b') 

 by CoUes's ligament {J.ria7igular ligameiit, ligamentuni ingui7iale refiexuni), consist- 



Diagram showing coverings of complete left indirect inguinal hernia. 



