Chirurgia operativa . Arteria femorale, h. Vena femorale. I. Guaina di vasi femorali, j. Vena safena. La stenosi si divide piacevolmente in direzioni spesso date, parallele al corso dei vasi epigastrici, o anche verso l'alto o leggermente verso l'esterno, questi vasi rischiano di subire lesioni. Se, d'altra parte, la sporgenza è della varietà diretta, e la teincisione è fatta verso l'alto e verso l'esterno, sotto l'impressione che sia una forma indiretta disposta di ernia, i vasi epigastrici saranno poi esposti toperil (Fig. 1116). Si vede, quindi, che la grande cautela dovrebbe essere beemployee

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Operative surgery . Femoral artery, h. Femoral vein. i. Sheath of femoral vessels, j. Saphenous vein. the stricture be divided agreeably to directions often given—parallel withthe course of the epigastric vessels—or even upward or slightly outward, these vessels will be in danger of injury. If, on the other hand, the protrusion be of the direct variety, and theincision be made upward and outward, under the impression that it is a dis-placed indirect form of hernia, the epigastric vessels will then be exposed toperil (Fig. 1116). It is readily seen, therefore, that great caution should beemployed in distinguishing between the two prior to cutting the constric-tion. It is practically impossible to discriminate between them until thecoverings of the sac are examined. The oblique variety has for a coveringthe cremaster muscle, which can readily be distinguished in an old hernia.This muscle never forms the covering of a direct hernia except when it OPERATIONS ON VISCKKA CONNECTED WITH PERITONAEUM. «^()9. Fig. 1115.—The course of deep epigastric and obturatorvessels. passes to tlie outer side of the conjoined tendon, wlien its coverings are similar to tliose of the oblique form. It therefore follows, from the anatom-ical relations, that when the creniastor does not form a co- ering the constriction should be divided up- w^ard and inward— that is, away from the ejiigastric vessels. If the ere master forms one of the coverings, then the constriction must be cut upward and outward, provided there be no evidence that it is a direct her-nia which has escaped to the outer side of the conjoined tendon. This latter condition is fortunately rare, and this, when taken in connection with the location of the tumor at its incipiency, should settle the question between the two. If, however, it be impracticable to settle the doubt, dull the edge of the knife by draw-ing it across a piece of metal, and then pro-ceed carefully to nick the neck of the con-striction in an upward di

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• bo
• bookcentury1800
• bookdecade1890
• bookidoperativesurgery02brya