Ligation of Internal Iliac 375 



membered :- The gluteal artery coming out of the pelvis above the 

 pyriformis is at a higher level than the pudic, which emerges below 

 that muscle. The line to cross its course must, therefore, be that 

 running from the posterior superior spine to the higher of the two 

 processes of bone, namely, to the great trochanter. The line for the 

 lower artery (pudic) runs to the lower land-mark the ischial tuberosity. 

 Further, the higher artery is at the junction of the highest third with 

 the middle third of the upper line, the lower artery, the pudic, being at 

 the junction of the lower third with the middle third of the lower line. 



Xiig-ation of the gluteal artery might be performed by making a 

 five-inch incision in the line just given, namely, from the posterior 

 superior spine of the ilium to the great trochanter, the body being placed 

 in the position which is adopted in the dissecting-room when the 

 buttock is being worked at. The coarse bundles of the great gluteus 

 having been reached and separated with a director, and the mass of 

 the muscle being traversed, the vessel is seen emerging above the 

 pyriformis. The limb is then raised to the level of the body, so as to 

 slacken the gluteus, and the ligature is applied as deeply as possible. 



The ilio-lumbar artery passes upwards and outwards from the 

 posterior division of the internal iliac, and beneath the psoas, and, as 

 its name implies, divides into an iliac and a lumbar branch. The iliac 

 branch supplies the iliacus, and anastomoses with the circumflexa ilii 

 and with one of the lower lumbar arteries, whilst the lumbar branch 

 supplies the quadratus lumborum, and likewise communicates with the 

 lower lumbar arteries, and, perhaps, even, with the intercostals. The 

 lumbar branch sends a twig into the spinal canal. The anastomoses 

 of the ilio-lumbar artery are of great importance when the common or 

 internal iliac is tied. 



The lateral sacral branch, or branches, run from the posterior 

 trunk of the internal iliac to the lateral part of the anterior surface of 

 the sacrum, whence anastomotic branches are sent to the sacra media, 

 to the branches of the opposite side, and to the rectum. Spinal 

 branches enter the anterior sacral foramina, and send out twigs on to 

 the gluteal region. 



Iteration. The internal iliac artery may be reached by a pro- 

 cedure like that described (p. 368) in the case of the common iliac ; the 

 external iliac is followed up until the bifurcation of the common trunk 

 is reached ; from that spot the internal iliac may be traced towards 

 the depths of the pelvis for about half-an-inch, and there tied. The 

 ureter would be raised from the artery in raising the peritoneum. 

 The vein is behind the artery. 



Collateral circulation would be abundant, the following vessels 

 anastomosing across the middle line with their fellows of the opposite 

 side : from the anterior trunk, the middle haemorrhoidal, three 

 vesical, uterine, vaginal, obturator, and internal pudic ; and from the 

 posterior trunk, the lateral sacral. 



In addition to these sources, the empty middle hasmorrhoidal 



