1770 



IirMAN ANATOMY. 



Peritoneum and sutaerous tissue 

 Infundit>ulifonn (transversalis fascia) 

 Internal oblique 



External oblique (intercolumnar fascia) 

 Superficial fascia and skin 



Deep epigastri 



u>efulnes, M denoting tin- mute of the hernia, and are occasionally of value as land- 

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



Tlie KLC of a complete oblique inguinal hernia (Fig. 1492) would carry with it 



i layer oj extra]., ritoneal connective tissue ; (2) that portion of the transversalis 



fascia known as the ////// ndibuliform fascia ; (3) the muscular fibres derived from the 



tran,ver,ali> and internal oblique muscles, and called the cremaster muscle ; (4) the 



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



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



i, in the scrotum the dartos layer ; (6) the skin. 



The cove-rings 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 outward, 

 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 



tnasvenahf or internal oblique), but the constriction of the 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. 



'/'tuts. 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 

 mu,des : the thigh Hexed 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 ..f the canal so as to remove folds and lessen lateral 

 bulging of the- MC and contents over the pillars of the external ring, and while 

 making p ie,,ure uith the thumb and fingers of one hand at that point to prevent its 

 other hand en. aides the fundus of the sac and with as evenly dis- 

 tributed force as i>o,,ible makes |>res,mv at first upward, then upward and outward, 

 in the line ! the (anal, -and finally backward. 



/ or in/trim/ in^ii hial hernia occurs in only 3-5 per cent of cases The 

 reasons for it, relative Infrequency luxe 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 ha, ben, subdivided by a fold corresponding to the plica 

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

 mne, angle ,,t ,,. former we find the abdominal wall strengthened (a) by the 



I the rec.us musde, uhi.-h extend, outward as far as'the pubic crest ; ( 



by Colle, i ligament , triangular /i\> ,,-/, //.;,//,,,// ,-,,//,. ,-,.,/,. } consist- 



Diagram sho\vin K tovcrings of complete left indirect inguinal hernia. 



