262 THE ABDOMEN AND PELVIS 



after they have been divided in the long axis of the cord. The 

 veins of the pampiniform plexus and the internal spermatic 

 artery can now be seen on the anterior surface of the sac, but 

 before they can be separated from it, the internal spermatic 

 (infundibuliform) fascia (p. 255) must be incised and stripped off. 

 If this is not done, difficulty will be experienced in separating 

 the vessels without injuring them. At the same time the 

 remaining veins and the ductus deferens should be freed from 

 the posterior aspect of the sac. The neck of the sac is carefully 

 isolated, ligated, and divided. It may be allowed to retract 

 into the abdomen or may be transplanted up the canal towards 

 the anterior superior iliac spine. The rest of the sac is removed, 

 but, if it is of the vaginal type (Fig. 78 (#)), the lower part may 

 be stitched up to form a closed tunica vaginalis testis. 



The same approach and method of dividing the coverings 

 of the cord are employed in such conditions as varicocele (p. 264), 

 hydrocele of the cord, and hydrocele of the tunica vaginalis. 



In infants or young people where the hernia is due to the 

 presence of a preformed sac and not to any inherent weakness 

 of the abdominal wall, the condition may be completely cured 

 by the removal of the sac, but it is sometimes advisable to insert 

 one or two stitches to narrow the subcutaneous inguinal ring or 

 to approximate the falx inguinalis (conjoined tendon) to the 

 inguinal ligament. 



In elderly patients it is necessary to strengthen the weak 

 area in the abdominal wall which has predisposed them to 

 hernia. The external oblique aponeurosis is split up along 

 the course of the canal and the lower borders of the internal 

 oblique and the falx inguinalis are denned. A few mattress 

 sutures may now be passed through the deep surface of the 

 thickened lower portion of the external oblique aponeurosis, 

 which is forming the inguinal ligament, and up through the falx 

 inguinalis so as to drag the latter structure downwards behind 

 the former. The close relationship of the femoral vessels to the 

 inguinal ligament must be borne in mind when these sutures 

 are inserted. In this way the posterior wall of the inguinal 

 canal is greatly strengthened. A similar effect can be produced 

 in the anterior wall by uniting the two portions of the external 

 oblique in such a way that they overlap. 



When sutures are being passed through the posterior wall 

 of the canal in the neighbourhood of the abdominal inguinal 

 (int. abd.) ring, the inferior epigastric vessels must be carefully 



