218. The operation for placing a ligature on the aorta should not be done by making an opening through the front of the abdomen, as has hitherto been proposed. It should in future be attempted and executed nearly in the same manner as the operation for placing a ligature on the common iliac, which has succeeded. The aorta bifurcates usually on the body of the fourth, or on the inter-vertebral substance between it and the fifth vertebra, although it may be higher or lower—a fact which cannot be ascertained previously to the operation; the most usual place is nearly opposite to the margin of the umbilicus on the left side. It is about half an inch above this that the ligature should be placed on the aorta, if this operation is ever done again, rather lower than higher, on account of the origin of the inferior mesenteric artery. As the aorta is to be reached by carrying the finger along the common iliac, the comparative situation of that vessel is next to be estimated.
The length of the two common iliac arteries varies according to the stature of the patient, and the place at which the aorta bifurcates. The common iliacs again divide into the external and internal iliacs, which division is usually opposite to the sacro-iliac symphysis. The length of the common iliac artery is therefore tolerably well defined, as scarcely ever exceeding two inches and three-quarters, and seldom being less than two inches. The external iliac is a little longer than the common iliac, and the place of subdivision of the common iliac into external and internal can always be ascertained, during an operation, by tracing the external iliac upward to its junction with the internal to form the common trunk, which proceeds upward and inward to the aorta. The left margin of the umbilicus being taken as a point opposite to that which may be presumed to be the part at which the aorta divides, and the situation of the external iliac becoming femoral being clearly ascertained, a line drawn between the two will nearly indicate the course of these two vessels; sufficiently so, at all events, to enable the operator to mark with his eye, or with ink, the place where he expects to tie the artery; and to regulate the length of the incision, so that this ideal spot may correspond to its center. It is necessary to recollect, also, that the whole of one hand and part of the other must be introduced into the wound, to enable the operator to pass a ligature round the artery, and to tie the knots: so that an external excision of less extent than five inches will not suffice, and six will afford a facility in operating, which will save pain to the patient and inconvenience to the operator. In calculating the length of the incision, allowance must be made for the size, obesity, and muscularity of the patient. If a rule be placed on the crest of each ilium, about one inch and a half behind the anterior superior spinous process, it will pass in a well-formed man across the junction of the fifth lumbar vertebra with the upper part of the sacrum, and a little way behind where the common iliac divides into external and internal. The center of an incision, six inches in length, beginning about half an inch above Poupart’s ligament, and about the same distance to the outside of the inner ring, and carried upward, will fall nearly on a line with this point. The incision should be nearly parallel to the course of the epigastric artery, but a little more to the outside, in order to avoid it and the spermatic cord, and having a gradual inclination inward toward the external edge of the rectus muscle; the patient being on his back, with the head and shoulders raised, and the legs bent on the trunk. The aponeurosis of the external oblique muscle having been opened inferiorly, is to be slit up for the whole length of the external incision; and the director having been first passed under the internal oblique muscle, through a small opening carefully made into it, it is to be divided in a similar manner. The transversalis is then to be cut through at the under part, and its tendinous expansion divided at the upper part, the greatest precaution being taken by the finger to prevent the peritoneum being injured. The fascia transversalis is then to be torn through at the lower and outer part, so that the fingers may be passed inward from 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 fingers inward and upward, until, passing over the psoas muscle, the external iliac artery is discovered by its pulsation. It is then to be traced upward and inward toward the spine, when its origin and that of the internal iliac from the common trunk will be felt. The point of the forefinger will then be nearly in the center of a line drawn from the umbilicus to the anterior superior spine of the ilium; hence the necessity for an incision six inches in length, if the artery is to be tied high up, which is to be accomplished by tracing it in a similar manner to its origin from the aorta.
The common trunk of the iliac arteries and the aorta itself may be tied by the same method of proceeding; the only difference which can be practiced with advantage will be to make the incision a little longer at its upper part, no inconvenience arising from the addition to the length of the external wound, while the subsequent steps of the operation will be much facilitated by it. The following method of proceeding, adopted in two cases in which I placed a ligature on the common iliac artery with a successful result, will bring the operation so graphically before the reader that it cannot be misunderstood, and may be readily followed in operating: I began the operation, the patient lying on the back, by an incision on the fore part of the abdomen, commencing an inch and a half below the inside of the anterior spine of the ilium, and the same distance within it, carrying it upward, and diagonally inward toward the edge of the rectus muscle above the umbilicus, so that the incision was between six and seven inches long. If the incision be made more outwardly, toward the side in a straight or vertical line from the ilium toward the ribs, great difficulty will be experienced in turning over the peritoneum with its contents, so as to place the finger on the last lumbar vertebra—an inconvenience which will be avoided by making the incision diagonally, and of the length directed.
After dividing the common integuments, the three layers of muscles were cut through in the most careful manner; the division of the transversalis muscle was attended with some difficulty, inasmuch as there was but little fascia transversalis, and the peritoneum was remarkably thin—as thin as white silver paper. On attempting to reach the under part on the inside of the ilium, so as to turn the peritoneum over, which in sound parts is always done without the least difficulty, I found that it could not be done on account of the tumor which projected inward adhering to it; some bleeding took place from the large veins which surrounded it, giving rise to the caution not to proceed further in that direction. At this moment, in spite of the greatest possible care that could be taken by Mr. Keate, who raised and protected the peritoneum, a very small nick was made in it, sufficient to show the intestine through it. Perceiving that I could not tie the internal iliac as I had at first intended, and that I must place the ligature on the common iliac, I tried to gain a greater extent of space upward; but where the tendon of the transversalis muscle passes directly across from the lower ribs to aid in forming the sheath of the rectus, the peritoneum is usually so thin and so closely attached to it that it can only be separated with great difficulty. I knew this from the operation I had before performed, when, in spite of all the precaution I could then take, the peritoneum was at this spot slightly opened. It occurred in the present instance, and the right lobe of the liver was thus exposed.
The opening thus made on the fore part of the abdomen was not large enough to admit two hands. The peritoneum being, however, separated a little from the posterior wall of the abdomen from the outside, by the fingers, for a cutting instrument was inadmissible, four of the fingers of one hand were introduced beneath it, and it was turned a little over toward the opposite side. In doing this it must be remembered that the peritoneum must be raised, the hand being pushed toward the back as little as possible, in order to avoid getting behind the fat commonly found in that part of the body, which would lead to the under edge of the psoas muscle instead of the upper surface, and thus render the operation embarrassing.
The peritoneum being carefully drawn over with its contents, I found I could only get one hand, or a little more, underneath it in search of the artery, the tumor below preventing any further detachment of the peritoneum in that direction. I therefore passed my finger across the psoas muscle, and it rested on the fifth lumbar vertebra. The common iliac artery was not to be felt, however, even as high up as the fourth lumbar vertebra, nor was the aorta; they had both risen with the peritoneum, and my finger resting on the spine was beneath them. Mr. Keate endeavored to raise or draw over the peritoneum, to give me an opportunity of seeing the vessels, but it could not be done. However, he felt the pulsation of the iliac artery, which had been raised with the peritoneum, to which I found it adhering. Carefully separating it with the end of the forefinger of the right hand, I passed a single thread of strong dentists’ silk, as it is termed, in a common solid aneurismal needle, by the aid of the thumb and forefinger of the left hand, round the artery without seeing it. I could then bring the artery a little forward by means of the aneurismal needle, when it appeared to be perfectly clear, and from the distance of the bifurcation of the aorta above, which could be distinctly felt, I calculated that the common iliac was tied exactly at its middle part. All pulsation below immediately ceased.
The two ends of the ligature were twisted, and the peritoneum replaced in its proper situation, care being taken that the two small openings into it should be well covered under the skin, so that they might not be in the line of the incision, and that they should be covered by newly divided healthy parts, so that they might thus adhere to each other. Three strong sutures and three or four smaller ones were put in through the skin, in order to prevent the parts bursting asunder from the movements of the patient. This operation was only formidable, as a whole, from the circumstance that space could not be obtained for the introduction of both hands; for, strange as it may appear, the safety of and ease in doing the operation depend on the first incision in the fore part of the abdomen being so large that the peritoneum containing the bowels may be freely drawn over by the expanded hands of the assistant, so that the operator can see what he is doing beneath. In my first case the whole of the parts under the peritoneum could be distinctly seen, and several gentlemen (not in the profession) who were present saw the common iliac artery in its natural situation.
The patient suffered little or nothing from the operation, which was performed on the Saturday; there was no augmentation of the pulse until Sunday evening, when it rose to 120; she then experienced some pain, which was materially diminished, although not altogether removed, by the abstraction of fourteen ounces of blood. At four in the morning, Mr. Hancock, now senior surgeon to the Charing Cross Hospital, took away fourteen ounces more, after which she had not a bad symptom. The bowels were not moved for the first four days. The temperature of the limb diminished, but not much, which may be attributed to its having been constantly rubbed night and day by two persons; and a hot brick, or bottles of hot water, covered with flannel, having been applied to the feet, of the temperature of from 120° to 140°. One nurse rubbed the lower part of the limb, and another the upper, for three days and three nights; if an interval of a few minutes occurred, a hot flannel was put on the limb. The friction was very slight, so as not to injure the cuticle. The patient occasionally dozed a little; still the same gentle friction was kept up. The ligature came away on the twenty-sixth day after the operation. The external incision healed very readily, but was followed, as is usual in all extensive wounds of the muscular wall of the abdomen, by a slight herniary projection, requiring the support of an abdominal bandage.
The situation of the ureter and rectum on the left side in this operation, and of the ureter and cæcum with its appendix on the right side, should be well understood, and it should be known that the ureter rises with the peritoneum. The relative situation of the common iliac artery and vein should be particularly attended to, when passing the ligature around the vessel. On the left side, the artery lies external and anterior to its commencement; on the right, the artery passes over the commencement of the vena cava and the left iliac vein, which do not follow the peritoneum when drawn toward the opposite side. The bowels should be thoroughly well evacuated before the operation is performed, but purgatives should not be given for some days after it has been done. The food should be liquid, and inflammation should be subdued by leeches, general bleeding, fomentations, and opium.
219. The aorta may be as readily tied by this mode of proceeding as the common iliac; and I am satisfied it is in this way such an operation ought to be performed, provided it become necessary to attempt it, which I suspect it will not be; for when an aneurism has formed so high up that it prevents the application of a ligature on the side on which the disease is situated, the common iliac will be more readily tied above it, instead of the aorta, by performing the operation on the opposite or sound side of the body; for as a ligature can be applied with great ease on the sound side on the middle of the common iliac artery, it requires very little more knowledge and dexterity to pass over to the opposite or diseased side, and tie the artery above the aneurismal tumor, the size of which would have prevented the operation being done on its own or the affected side. The placing a ligature on the aorta for an aneurism in the pelvis will thus be rendered unnecessary—a most important result, deduced from the operation described.