404 THE INFERIOR EXTREMITY 



in the lax, fatty space which contains the proximal subinguinal 

 lymph glands. 



During attempts to reduce a femoral hernia the thigh should 

 be semiflexed and slightly adducted in order to relax the pec- 

 tineus, the fascia lata, and the inguinal ligament. Gentle 

 manipulations are then carried out to make the protrusion 

 retrace the course of its original path, first distally and medially 

 till it passes through the fossa ovalis, and finally, backwards 

 and proximally through the femoral ring. 



The surgical approach may be by means of an incision parallel 

 and just distal to the medial part of the inguinal ligament, 

 or a semilunar incision may be utilised, the base of the flap 

 being medial, with the object of keeping the wound as far as 

 possible from the genitalia. After division of the skin, super- 

 ficial fascia and vessels, a little blunt dissection reveals a mass 

 of fat quite distinct from the surrounding fatty areolar tissue. 

 The coverings derived from the fascia cribrosa and the wall of 

 the femoral canal can rarely be identified. Further blunt dis- 

 section is carried out until the neck of the tumour is isolated at 

 the femoral ring, and while this is being done the union of the 

 great saphenous with the femoral vein may be exposed just 

 proximal to the distal edge of the fossa ovalis. The fatty tissue, 

 which consists of the septum femorale, is then carefully incised 

 step by step in a search for the hernial sac. Sometimes there 

 is no sac and the tumour is simply a lipoma growing in the 

 septum femorale. If a sac is found it is carefully isolated, 

 ligated, and transplanted upwards by carrying the long ends of 

 the ligatures upwards through the femoral ring and bringing 

 them out above the inguinal ligament and there tying them. 



Many methods have been introduced in order to close, narrow, 

 or obstruct the femoral canal, but owing to the rigidity of the 

 parts above and the constant movements of the parts below, 

 none of them have proved altogether satisfactory. A strong 

 purse-string catgut suture may be utilised to pucker up the fascia 

 in the region. It is passed through the inguinal ligament, the 

 fascia lata, the lateral border of the fossa ovalis, and the fascia 

 over the pectineus, and care must be taken not to injure the 

 femoral vein. Another method is to dissect up a flap of the pec- 

 tineal fascia and stitch it to the inguinal ligament, thus closing 

 the femoral ring. 



Femoral hernia occurs more frequently in women than in 

 men. This is partly on account of the greater width of the 



