7(50 SURGICAL ANATOMY OF INGUINAL HERNIA. 



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anterior superior spine of the ilium, to the spine of the pubes, is termed Poupart's 

 ligament or the crural arch ; and that portion which is inserted into the pectineal 

 line, is termed Gimbernat's ligament. 



Just above and to the outer side of the crest of the pubes, a triangular interval 

 is seen in the aponeurosis of the External oblique, called the external abdominal 

 ring ; it transmits the spermatic cord in the male, and the round ligament in the 

 female. This aperture is oblique in direction, somewhat triangular in form, and 

 corresponds with the course of the fibres of the aponeurosis. It usually measures 

 from base to apex about an inch, and transversely about half an inch. It is 

 bounded below by the crest of the os pubis ; above, by a series of curved fibres, 

 the inter columnar, which pass across the upper angle of the ring so as to increase 

 its strength ; and on either side, by the free borders of the aponeurosis, which are 

 called the columns or pillars of the ring. 



The external pillar, which, at the same time, is inferior from the obliquity of 

 its direction, is the strongest ; it is formed by that portion of Poupart's ligament, 

 which is inserted into the spine of the pubes ; it is curved round the spermatic 

 cord, so as to form a kind of groove, upon which it rests. 



The internal or superior pillar is a broad, thin, flat band, which interlaces with 

 its fellow of the opposite side, in front of the symphysis pubis, that of the right 

 side being superficial. 



The external abdominal ring gives passage to the spermatic cord in the male, 

 and round ligament in the female ; it is much larger in men than women on 

 account of the large size of the spermatic cord, and hence the greater frequency 

 of inguinal hernia in the former sex. 



The intercolumnar fibres are a series of curved tendinous fibres, which arch 

 across the lower part of the aponeurosis of the External oblique. They have 

 received their name from stretching across between the two pillars of the external 

 ring ; they increase the strength of the membrane which bounds the upper part 

 of this aperture, and prevent the divergence of the pillars from one another. They 

 are thickest below, where they are connected to the outer third of Poupart's 

 ligament, and taking a curvilinear course, the convexity of which is directed 

 downwards, are inserted into the linea alba. They are much thicker and stronger 

 at the outer angle of the external ring than internally, and are more strongly 

 developed in the male than in the female. These fibres are continuous with a thin 

 fascia, which is closely connected to the margins of the external ring, and has 

 received the name of the intercolumnar or external spermatic fascia ; it forms a 

 tubular prolongation around the outer surface of the cord and testis, and incloses 

 them in a distinct sheath. The sac of an inguinal hernia, in passing through the 

 external abdominal ring, receives an investment from the intercolumnar fascia. 



The finger should be introduced a slight distance into the external ring, and, if 

 the limb is extended and rotated outwards, the aponeurosis of the External oblique, 

 together with the iliac portion of the fascia lata, will be felt to become tense, and 

 the external ring much contracted ; if the limb is, on the contrary, flexed upon 

 the pelvis and rotated inwards, this aponeurosis will become lax^ and the external 

 ring sufficiently enlarged to admit the finger with comparative ease ; hence the 

 latter position should always be assumed in cases where the taxis is applied for 

 the reduction of an inguinal hernia, in order that the abdominal walls may be as 

 much relaxed as possible. 



The aponeurosis of the External oblique should be removed by dividing it across in the same 

 direction as the external incisions, and reflecting it outwards ; great care is requisite in separating 

 it from the aponeurosis of the muscle beneath. The lower part of the Internal oblique and the 

 Cremaster are then exposed, together with the inguinal canal, which contains the spermatic cord 

 (fig. 381). The mode of insertion of Poupart's and Gimbernat's ligaments into the pubes should 

 also be examined. 



Pouparfs ligament or the crural arch extends from the anterior superior spine 

 of the ilium to the spine of the pubes. It is also attached to the pectineal line 

 to the extent of about an inch, forming Gimbernat's ligament. Its general 



