INTERNAL HERNIOTOMY. 529 



length of the sac, is made through, the skin covering the hernial 

 swelling. After dividing the subcutaneous coverings to a similar 

 extent, an attempt is made to reach the hernial ring. Large vessels 

 are ligatured to keep the field of operation clear, firm portions of 

 connective tissue divided with the scissors or knife. By introducing 

 the finger into the depths, one can discover the narrowest, that is, 

 the strangulated, spot, which is then widened with a herniotome 

 or tenotome outside the peritoneum. This effected, reduction by 

 taxis becomes easy, and the wound is at once carefully cleansed and 

 sutured after the manner described under non-strangulated hernia. 

 Internal herniotomy requires similar preparations. The incision 

 is made through the skin in the same way, and the hernial coats 

 lying beneath divided with a knife as far as the peritoneum. A 

 little fold of the latter, at the base of the hernial sac, is then raised 

 with forceps, and cut through close below the forceps with a knife 

 held horizontally, producing a small opening. Employing a director 

 and blunt-pointed scissors this opening is enlarged, the index finger 

 passed into the hernial sac, and the peritoneum incised as far as 

 the neck of the sac, the finger meanwhile pressing back the hernial 

 contents and protecting them from injury. The finger is now passed 

 into the hernial opening, the herniotome introduced alongside it, 

 and the ring or neck of the hernial sac divided at the point of 

 strangulation. A slight incision suffices to enable the contents of 

 the sac to be returned to the abdomen, unless the hernia is 

 adherent. 



In umbilical and abdominal hernise, hernia knives are replaced 

 by blunt-pointed tenotomes of various forms. A special herniotome 

 is only necessary in inguinal hernia in the horse. 



Internal herniotomy has the advantage over the external 

 operation that one can determine the condition of the strangulated 

 bowel, and should the latter prove to be necrotic, can either proceed 

 to further treatment or resection of the necrotic portion. Reposition, 

 under these circumstances, would destroy any chance of recovery. 

 It should, however, be repeated that dark coloration does not always 

 indicate necrosis. 



It is necessary in such cases promptly to decide whether to attempt 

 resection of the necrotic bowel, a proceeding which, though certainly 

 offering greater chance of success in carnivora than in herbivora, 

 especially in horses, is even in them eminently fatal. Incarcerated 

 portions of omentum, which, however, are seldom met with, are 

 first ligatured with aseptic material and then cut off, and the wound 

 treated as before described. It is of the highest importance to secure 



R.S. M M 



