848 



ILIAC ARTERIES. 



unless there be something peculiar in the par- 

 ticular case to justify its adoption. The ad- 

 vantages of the second method have been 

 partly stated ; to these is to be added that the 

 line of incision will be made to correspond more 

 to that of the artery than by the last method, 

 and consequently the wound will be less oblique 

 in depth, whence probably there will be less 

 difficulty experienced in holding aside the parts 

 which intervene between the surface and the 

 vessel; and certainly the operator, who may 

 be apprehensive of injuring the epigastric and 

 circumflex iliac arteries or the spermatic process, 

 will do well to adopt it. Still for some reasons 

 I feel disposed to prefer the last, for 1, it re- 

 quires less disturbance of the peritoneum ; 2, 

 it appears to me that the exposure of the vessel 

 must be greatly facilitated by carrying the lower 

 extremity of the incision across the course of 

 the artery to its inner side, which is not accom- 

 plished by the second method ; 3, a semilunar 

 line of incision furnishes a wound of greater 

 length, and capable of being more widely 

 opened than a straight one, while caution will 

 secure the spermatic process and the epigastric 

 artery from injury; and if a branch of the 

 circumflex ilii be, as it is likely to be, divided, 

 it may be tied with ease. This was the me- 

 thod adopted by Mott in the operation, in 

 which he tied the primitive iliac artery ; a case 

 which sufficiently establishes the adequacy of 

 this plan for the high ligature of the vessel, at 

 the same time that it displays in a strong light 

 the difficulties for which the operator must be 

 prepared. In such cases the method of di- 

 viding the internal oblique and transversalis 

 used by Mott may be adopted with advantage, 

 viz. after having opened the fascia transversalis 

 to insinuate the finger between it and the peri- 

 toneum, and guided by it to divide both mus- 

 cles at once from within. It must not be 

 forgotten that it is not uncommon to find the 

 ureter crossing the internal iliac artery, upon 

 the right side, near its origin. 



Operations for the ligature of the internal 

 iliac artery. The method adopted in this 

 operation by Stevens, by whom the artery was 

 first tied, and that recommended by the ma- 

 jority of writers, is similar in principle to the 

 first plan of Abernethy for the external iliac, 

 and differs from it only in the length of the 

 incision, which, according to Guthrie, should 

 be five inches, beginning about half an inch 

 above Poupart's ligament and about the same 

 distance to the outside of the inner ring; it 

 should be nearly parallel to the course of the 

 epigastric artery, but a little more to the out- 

 side, in order to avoid it and the spermatic 

 cord, and have a gradual inclination inwards 

 toward the external edge of the rectus muscle : 

 according to Hodgson the centre of it should 

 be nearly opposite the superior anterior spinous 

 process of the ilium. The aponeurosis of the 

 external oblique, and the internal oblique and 

 tranversalis muscles having been divided with 

 the same precautions to avoid the peritoneum, 

 as in the other case, the fascia transversalis is 

 to be torn through at the lower and outer part, 

 so that the fingers may be passed outward 



towards the ilium, and the peritoneum detached 

 from the iliac fossa, and turned with its contents 

 inward by a gradual and sidelong movement of 

 the fore and second finger inwards and upwards, 

 until passing over the psoas muscle the ex- 

 ternal iliac artery is discovered by its pulsation. 

 This is then to be traced upward and inward 

 toward the spine, where the origin of it and 

 the internal iliac from the common iliac trunk 

 will be felt. The artery is to be traced down- 

 ward from its origin and separated with care 

 from its connections, and more especially the 

 vein. The sides of the wound should now be 

 separated and kept apart with curved spatulae 

 in order that the surgeon may, if possible, 

 see the artery, and have sufficient space for 

 passing the ligature. Great care must be taken t 

 to avoid every thing but the artery ; the peri- 

 toneum which covers, and the ureter, which 

 crosses it, must be particularly kept in mind ; 

 the latter may be separated with ease, and 

 usually accompanies the former as it is being 

 detached from the artery. The situation of the 

 external iliac artery and vein, which have been 

 crossed to reach it, must be always recollected, 

 and, if possible, they should be kept out of 

 the way and guarded by the finger of an 

 assistant.* This method has in this case a 

 recommendation, which it does not possess for 

 the other itiacs, viz. that, as it is necessary in 

 tying the internal iliac to descend more or less 

 into the pelvis, it is desirable that the external 

 wound should be as near as possible to the 

 aperture of the cavity, but the danger to the 

 peritoneum must be even greater because of 

 the greater extent to which it must be separated, 

 and the closer attachment of it to the ten- 

 dinous than the muscular structure of the 

 abdominal wall. It, therefore, seems to me a 

 question whether even in this case the line of 

 incision here recommended should be adopted, 

 and whether it would not be better to have 

 recourse to that either of Roux or Cooper. 

 Of the two perhaps the former may be best 

 adapted to the internal iliac for the reason just 

 assigned ; though, if the inferior extremity of 

 the incision be not carried beyond the middle 

 of Poupart's ligament, difficulty must be ex- 

 perienced in exposing the vessel and passing 

 the ligature; therefore here again I am dis- 

 posed to prefer the semilunar line of Cooper, 

 only not brought so close to the crural arch as 

 for the external iliac, and prolonged, as di- 

 rected by Velpeau, two inches at its external 

 extremity. 



It is recommended to pass the ligature from 

 within outward because the internal iliac vein 

 is posterior to the artery ; this appears to me, 

 however, not the most judicious plan, by it the 

 point of the needle must be first carried out- 

 ward and then forward and inward in order to 

 pass round the vessel : now the external iliac 

 vein is immediately external to and crossed by 

 the artery ; the junction of the two iliac veins 

 is also external to the artery, and the internal 

 one, though posterior, is at the same time ra- 

 ther external to it. In such a case the course 



* Guthri* on Diseases of Arteries, p. 371-2. 



