THE ABDOMEN. 



387 



as it passes through the transversalis fascia. The deep epigastric artery is always 

 along the inner side of the neck of the sac, therefore division of the stricture must 

 be either upward or up and out, never inward (Fig. 397). 



Operation for Radical Cure. This has been systematized by Bassini of 

 Padua. The neck of the sac having been exposed by incising the aponeurosis of the 

 external oblique, and the cord separated from it, the intestine is to be replaced and 

 the sac ligated as high as possible and cut away. The cord is then raised and the 

 arching fibres of the internal oblique (and transversalis) are sutured beneath it to 

 Poupart's ligament. The cord is to be replaced, and the cut edges of the external 

 oblique are sewed together down to the external ring, leaving sufficient room for the 

 exit of the cord (Fig. 398). 



Direct Inguinal Hernia. This is so called because it comes directly through 

 the abdominal walls, and not obliquely down through the inguinal canal. It makes 

 its appearance in the neighborhood of the external ring (Fig. 399). 



Shelving edge of 

 Poupart's ligament 



Aponeurosis of exter- 

 nal oblique incised 

 and turned back 



The arching fibres 

 and conjoined ten- 

 don of the internal 

 oblique and trans- 

 versalis sewn to the 

 edge of Poupart's 

 ligament tinder the 

 spermatic cord 



Spine of pubis 



FIG. 398. Bassini's operation for the radical cure of oblique inguinal hernia. 



HesselbacKs Triangle. Hesselbach's triangle is seen from the interior of the 

 abdomen; it has on its outer side the deep epigastric artery, on its inner side the 

 edge of the rectus muscle, and as its base Poupart's ligament. Direct inguinal 

 hernia pierces the abdominal walls through this triangle. On looking at the 

 abdominal wall from the inside, five folds are seen. In the median line the urachus 

 passes from the umbilicus to the top of the bladder; farther out are the folds formed 

 by the obliterated hypogastric arteries (plica hypogastrica) ; and still farther out the 

 folds containing the deep epigastric arteries (plica epigastrica). The fossa between 

 the urachus and hypogastric artery is called the internal ingidnal fossa (fovea 

 supravesicalis) ; that between the hypogastric and deep epigastric arteries, the 

 middle inguinal fossa (fovea inguinalis medialis), and that to the outside of the 

 epigastric artery the external inguinal fossa (fovea inguinalis lateralis). An 

 indirect or oblique inguinal hernia enters the abdominal walls at the external inguinal 

 fossa, to the outer side of the epigastric artery. A direct hernia almost always enters 

 the middle inguinal fossa between the hypogastric and epigastric arteries. The 

 hypogastric fold passes up behind the middle of the external ring close to the outer 



