A Manual of the Operations of Surgery / For the Use of Senior Students, House Surgeons, and Junior Practitioners

by Joseph Bell

1. The sac should be opened in every case where there is any reason for doubt about the condition of the bowel, where there has been long-continued vomiting, or much tenderness on pressure.

2. Even in cases in which there is every reason to believe the bowel is perfectly sound, the sac should be opened, unless the whole contents can be easily and completely reduced out of the sac into the belly, as in cases where this cannot be done there probably exist either a stricture in the neck of the sac itself, or adhesions of the bowel to the sac. We should endeavour to avoid opening the sac in cases of old scrotal hernia of large size, where the symptoms have not been urgent, especially in large unhealthy hospitals, as the risk of peritonitis is so great. Antiseptic precautions seem considerably to diminish the risk of opening the sac.

If the sac then is not to be opened, the rest of the operation is very simple. Endeavour to reduce the bowel out of the sac, and then return the sac itself, unless the hernia is of old standing, and adhesions prevent its reduction. A few silver stitches to close the wound and a carefully adjusted pad are now all that is requisite.

If the sac is to be opened, how can it be done with least danger to the bowel?

If the hernia is small, and it is possible to define it all, the sac should be opened at its lower end, as there a small quantity of serous fluid which intervenes between the sac and the bowel will be found. Where this is present, there is no danger of wounding the bowel, as the sac can be easily pinched up; but this is by no means invariably the case, so great care should always be taken. A small portion of the wall being thus pinched up should be divided in the same manner as the layers of cellular tissue were divided in exposing the sac. A few drops of serum will then escape, and the glistening surface of the bowel be exposed; the finger should then be introduced at the opening, and the incision enlarged by a probe-pointed bistoury. If the hernia is small the sac should be slit up to its full extent; if large, only a sufficient portion of the neck should be opened. As soon as the opening in the sac is large enough to admit the point of the operator's forefinger, it should be inserted so as to protect the intestines, and the remainder of the sac slit up on it as a guide.

The sac thus opened, the next step is to divide the constriction, wherever it be. It is most likely to be found at the neck of the sac, just where it protrudes through the internal ring in an oblique hernia, or through the tendons of the transversalis and internal oblique, where the hernia is direct. Now, this constriction might be divided in any direction were it not for the risk of wounding the epigastric artery, and also of injuring the spermatic cord, which is in close relation to the neck of the sac of an oblique hernia.

Wound of the epigastric artery is the chief danger, for in all cases it is close to the neck of the sac. Were its position in relation to the neck of the sac constant, it might be easily avoided by an incision in the opposite direction; but as this relation varies according to the nature of the hernia, an element of danger is introduced. Thus, in oblique inguinal ruptures, where the sac passes out through the internal ring (Fig. xxxii. ir), the artery will always be found to the inside of the neck of the sac; while in direct herniæ, where the bowel has made its escape through the triangle of Hesselbach (Fig. xxxii. +), and passed through the conjoint tendon straight to the external ring, the epigastric artery will be found on the outside of the neck of the sac. In recent herniæ the differential diagnosis is comparatively easy, but in those of old standing and large size, in which the obliquity of the canal has been much diminished, it is almost impossible to tell of what kind the hernia originally was, and consequently to determine in which direction it is safe to incise the neck of the sac.

Such being the case, the best rule is to incise the neck of the sac directly upwards, i.e. in a line parallel with the linea alba, and also to cut it very cautiously bit by bit, in every case, if possible, with the finger inserted as a guide to the position of a vessel and a protection to the gut.

The spermatic vessels lie sometimes behind, sometimes on either side of the sac, and in very old herniæ may be separated from each other so as really to surround the sac. The cut directly upwards is also the safest for them.

All constrictions being overcome, it is not sufficient merely to push back the gut into the belly. Its condition must be carefully examined, and it must be decided whether the constriction has caused gangrene or not. To examine this properly, it is generally best to pull down an inch or two more of the gut, so as thoroughly to bring into view the constricted portion, as it is most likely to be fatally nipped.