220. If the internal iliac is to be tied, the operator traces it downward from its origin, in preference to passing his finger from the external iliac artery inward in search of it. Having placed the point of his forefinger on the vessel at the part where he intends to pass his ligature, he scratches with the nail upon and on each side of it, so as to separate it from its cellular attachments, and from the vein which accompanies, but lies behind it. Thus far the operator proceeds by feeling; but it is now necessary that the sides of the wound should be separated, and kept apart by blunt spatulæ curved at the ends, so as to take up as little space as possible, and not to injure the peritoneum. The surgeon should, if possible, see the artery, and the ligature carried on the eye of a bent probe, or a convenient aneurismal needle, should be passed under it from within outward, when it should be taken hold of with the forceps; the probe or needle should then be withdrawn, and the ligature firmly tied twice, or with a double knot. Great care must be taken to avoid everything but the artery. The peritoneum which covers it and the ureter which crosses it must be particularly kept in mind. The situation of the external iliac artery and vein, which have been crossed to reach it, must always be recollected, and, if there be sufficient space, they should be kept out of the way, and guarded by the finger of an assistant.
221. The external iliac artery has been so often and so successfully tied that a description of the two methods of proceeding commonly adopted will suffice, with a few additional remarks. The first, recommended by Mr. Abernethy, is in accordance with the operations on the common, and on the internal iliac. The patient being laid on his back, with the shoulders slightly raised, and the legs bent on the trunk, an incision is to be made about three inches and a half in length in the direction of the artery, terminating over or a little above Poupart’s ligament. The aponeurosis of the external oblique muscle will be exposed, and an opening being made into it, a director is to be introduced, and it is to be slit up to the extent of the external incision. The internal oblique and transversalis muscles are then to be “nicked,” so as to allow a director or the point of the finger to be introduced below them, when they also are to be divided, the finger separating them from the fascia transversalis and the peritoneum. The fascia transversalis running from Poupart’s ligament to the peritoneum is now to be torn through with the nail, immediately over the pulsating artery, and the peritoneum is to be separated by the finger, and pushed upward until sufficient room has been obtained; which in this, as well as in all other operations on the iliac arteries, is sometimes difficult on account of the protrusion of the intestines covered by the peritoneum, when the patient is not sufficiently tranquil. The artery is yet at some depth; it is covered by a dense cellular membrane, connecting it to the vein on its inside, which must be torn through with the nail. The anterior crural nerve is separated from the artery by the psoas muscle, at the outer edge of which it lies. The aneurismal needle should be passed between the vein and the artery, and the point made to appear on the outside of the latter.
In this operation the ligature is placed on the external iliac, above where it gives off the epigastric and the circumflexa ilii arteries; as the operation is very much the same as that already described, with the exception of the incision being shorter and nearer to Poupart’s ligament, it is obvious, if it were found necessary from disease to tie the artery higher up, or even to tie the common iliac, that it might be done by merely enlarging the wound. It is therefore the best mode of proceeding when the aneurismal swelling in the groin has encroached on Poupart’s ligament.
Another method has been recommended by Sir Astley Cooper, which is perhaps more followed where there is little doubt of the artery being sound.
“The patient being placed in the recumbent posture, on a table of convenient height, the incision is to be begun within an inch of the anterior superior spinous process of the ilium, and is to be extended downward in a semicircular direction to the upper edge of Poupart’s ligament. This incision exposes the tendon of the external oblique muscle; in the same direction the above tendon is to be cut through, and the lower edges of the internal oblique and transversalis abdominis muscles exposed; the center of these muscles is then to be raised from Poupart’s ligament; the opening by which the spermatic cord quits the abdomen is thus exposed, and the finger passed through this space is directly applied upon the iliac artery, above the origin of the epigastric and circumflexa ilii arteries. The iliac artery is placed upon the outer side of the vein; the next step in the operation consists in gently separating the vein from the artery by the extremity of a director, or by the end of the finger. The solid curved aneurismal needle is then passed under the artery, and between it and the vein from without inward, carrying a ligature, which, being brought out at the wound, the needle is withdrawn, and the ligature is then tied around the artery, as in the operation for popliteal aneurism. One end of the ligature being cut away, the other is suspended from the wound, the edges of which are brought together by adhesive plaster, and the wound is treated as any other containing a ligature.”
This method of operating will suffice when the artery is to be tied for an aneurism which does not extend as high as Poupart’s ligament. When it does, the operator will be so much inconvenienced by it, while the sound part of the artery above the tumor will be so much in a hollow behind it in the pelvis, that a ligature cannot readily be passed around it; the disturbance to the peritoneum will be much greater, and much more likely to give rise to peritonitis, than if the incision were made an inch longer on the face of the abdomen. The surgeon, instead of searching for the artery, as Sir Astley Cooper has directed, through the passage by which the spermatic cord quits the abdomen, and thus passing the fingers directly under the peritoneum, will find it very much for his own ease, and for the advantage of his patient, to pass his fingers under the peritoneum from the inside of the wall of the ilium, from which it readily separates, and thus approach the artery from the outside instead of from below. He will obtain more room, reach the artery easily above the origin of the circumflexa ilii, and avoid that disturbance of the peritoneum, in applying the ligature, which often leads to inflammation. The ligature should be passed under the artery from within outward, so as to avoid the vein, which I have seen injured by passing the needle from without inward.
If the surgeon have unluckily divided the epigastric artery, either in this or in any other operation, all that he has to do is to enlarge the incision, and tie both ends of the divided vessel; I have no hesitation in saying it will not be of any consequence, either in this operation or in one for hernia.
222. In all cases of aneurism of the gluteal and sciatic arteries, the internal iliac artery should be tied, instead of an operation on the part itself. In all cases of wounds of those arteries, which are the only ones rendering an operation for placing a ligature on these vessels necessary, the wound should in a great measure regulate the course of the incision. The operation is an act of simple division, first through the common integuments for the space of five inches, then through and between the fibers of the gluteus muscle to the same extent; a dense aponeurosis covering the vessels is to be next divided, when the bleeding will lead to the injured vessel. Place the body on the face, turn the toes inward; commence the incision one inch below the posterior spinous process, and one inch from the sacrum; carry it on toward the great trochanter in an oblique direction to the extent of five inches. Divide the gluteus muscle and the aponeurosis beneath it, and seek for the artery as it escapes through the upper and anterior part of the sciatic notch, lying close to the bone. If the vessels of the gluteus muscle bleed, so as to be troublesome, and cannot be stopped by compression, they must be secured.
If the sciatic artery be the vessel injured, the incision should be made in the same direction, but about an inch and a half lower down. If the course of the wound render it doubtful which artery has been injured, the incision should be as nearly as possible between the two lines directed, the wound being always the best guide; care should be taken in every instance to include nothing in the ligature but the artery.
Dr. Tripler, of the United States Army, was called to a person who had fallen backward with great force on a glass bottle, which had thus been driven into the right buttock, within an inch of the ischiatic notch. The fingers passed into the wound could be felt on the inside of the thigh. The man was deluged with blood, and in a state of syncope. The wound was plugged and bandages applied. Several hemorrhages took place, and on the thirteenth, five days after the receipt of the injury, the wound was enlarged, and the gluteal artery tied as it emerged from the pelvis. The bleeding ceased for three hours, when it returned with as much force as ever. After various ineffectual attempts to suppress the bleeding by pressing on the external iliac and femoral arteries, it was determined to tie the internal iliac, which was done in a very satisfactory manner, and the bleeding did not return. The man died three days after the operation, and an examination after death took place; but, strange to say, no notice is taken, no mention whatever is made of the wounded vessel. It is simply remarked that the last ligature was found embracing the internal iliac artery an inch below the bifurcation, and a firm coagulum already deposited above the point of ligation.