1316 THE ORGANS OF DIGESTION 



(lateral implantation). The two ends of the excluded portion are fastened to the skin and are 

 left open. 



In ascites resulting from cirrhosis of the liver, benefit occasionally follows the performance of 

 Talma's operation (epiplopexy}. The abdomen is opened and the omentum is sutured to the 

 anterior abdominal wall or in the abdominal wound, in the hope of establishing a more free 

 communication between the portal and systemic circulations, thus lowering portal pressure. 



Hernia. -The two chief sites at which external hernia may take place are the inguinal region 

 and the crural canal. The description of the inguinal canal and its relations will be found on 

 pages 438 to 440, and that of the crural canal on pages 504 and 686. Some points in regard 

 to the disposition of the peritoneum in these regions may, however, be recapitulated here. 



Between the upper margin of the front of the pelvis and the umbilicus, the peritoneum, 

 when viewed from behind, will be seen to be raised into fine folds with intervening depressions, 

 by more or less prominent bands which converge to the umbilicus. The urachus, situated in 

 the middle line, is covered by a fold of peritoneum known as the plica urachi. On either side of 

 this a fold of peritoneum around the impervious hypogastric artery forms the plica hypogastrica. 

 To either side of these three cords is the deep epigastric artery covered by the plica "epigastrica. 

 Between these raised folds are depressions constituting the so-called fossae. The most internal, 

 between the plica urachi and plica hypogastrica, is known as the internal inguinal fossa (fovea 

 supravesicalis). The middle one is situated between the plica hypogastrica and plica epigas- 

 trica, and is termed the middle inguinal fossa (fovea inguinalis medialis). The external one is 

 external to the pltea epigastrica and is known as the external inguinal fossa (fovea inguinalis 

 lateralis). Occasionally the deep epigastric artery corresponds in position to the impervious 

 hypogastric artery, and then there is but one fold on each side of the middle line. In the usual 

 position of the parts the floor of the external inguinal fossa corresponds to the internal abdominal 

 ring, and into this fossa an oblique inguinal hernia descends. To the inner side of the plica 

 epigastrica are the two internal fossae, and through either of these a direct hernia may descend. 

 The whole of the space between the deep epigastric artery, the margin of the Rectus and Pou- 

 part's ligament, is known as Hesselbach's triangle. Below the level of Poupart's ligament 

 is a small depression corresponding to the position of the crural ring. It is known as the femoral 

 fossa, and into it a femoral hernia descends. 



Inguinal Hernia. Inguinal hernia is that form of protrusion which makes its way through 

 the abdomen in the inguinal region. There are two principal varieties of it external or oblique, 

 and internal or direct. 



In oblique inguinal hernia the intestine escapes from the abdominal cavity at the internal ring, 

 pushing before it a pouch of peritoneum which forms the hernial sac. As it enters the inguinal 

 canal it receives an investment from the extraperitoneal tissue and is enclosed in the infun- 

 dibuliform fascia. In passing along the inguinal canal it displaces upward the arched fibres 

 of the Transversalis and Internal oblique, and receives a covering of Cremaster muscle and 

 cremasteric fascia. It then passes along the front of the spermatic cord and escapes from the 

 inguinal canal at the external ring, becoming invested by intercolumnar fascia. Lastly, it 

 descends into the scrotum, receiving coverings from the superficial fascia and the integument. 



The seat of stricture in oblique inguinal hernia is at either the external or internal abdominal 

 ring; most frequently in the latter situation. If it is situated at the external ring, the division of 

 a few fibres at one point of the circumference is all that is necessary for the replacement of the 

 hernia. If at the internal ring, it is necessary to divide the aponeurosis of the External oblique 

 so as to lay open the inguinal canal; in dividing the aponeurosis the incision should be directed 

 parallel to Poupart's ligament, and the constriction at the internal ring should then be divided 

 directly upward. 



When the intestine passes along the inguinal canal and escapes from the external ring into the 

 scrotum, it is called complete oblique inguinal or scrotal hernia. If the intestine does not escape 

 from the external ring, but is retained in the inguinal canal, it is called incomplete inguinal 

 hernia or bubonocele. In each of these cases the coverings which invest it will depend upon 

 the extent to which it descends in the inguinal canal. 



There are some other varieties of oblique inguinal hernia (Figs. 1058 to 1062) depending 

 upon congenital defects in the processus vaginalis, the pouch of peritoneum which precedes 

 the descent of the testis. Normally this pouch is closed before birth, closure commencing at 

 two points viz., at the internal abdominal ring and at the top of the epididymis, and gradually 

 extending until the whole of the intervening portion is converted into a fibrous cord. From 

 failure in the completion of this process, variations in the relation of the hernial protrusion to 

 the testis and tunica vaginalis are produced; these constitute distinct varieties of inguinal 

 hernia viz., congenital, infantile, encysted, and hernia of the funicular process. 



Where the processus vaginalis remains patent throughout, the cavity of the tunica vaginalis 

 communicates directly with that of the peritoneum. The intestine descends along this pouch 

 into the cavity of the tunica vaginalis which constitutes the sac of the hernia, and the gut lies in 

 contact with the testis. Though this form of hernia is termed congenital, the term does not imply 

 that the hernia existed at birth, but merely that a condition is present which may allow of the 



