—The common iliac artery is best tied by an incision commenced parallel with Poupart’s ligament and curved upward and outward. The abdominal muscles and fascia having been divided, with the least possible injury to their fibers, the peritoneum is detached from the iliac fascia, the patient being turned upon the side in such a way that gravity may assist in the exposure of the vessel behind the peritoneum. A needle of medium length, and strong, with oblique lateral curve, should be passed from within outward, the vein lying behind the artery on the right side, near to its inner side, and behind on the left side. In the fossa thus formed, and lying upon the psoas, will be found not only the common trunk but the external cutaneous nerve, running downward and outward, and also the iliac branch of the iliolumbar artery.
The operator may decide, for some reason, to open the abdomen directly, and to go through from front to rear, drawing aside the intestinal loops, with the patient in the Trendelenburg position, exposing the main trunk by a small incision through the posterior peritoneum and applying the ligature there. By this same transperitoneal method the internal iliac may be attacked. Its course inward and downward, rather than outward, makes it more easy of attack in this way. The ureter, which lies in front of the artery, should be raised, along with the peritoneum, in order that it may be avoided. This vessel has thus been tied for hypertrophy of the prostate, for inoperable cancer of the uterus, during excision of the rectum, and even for the cure of vascular tumors or aneurysms affecting its terminal arteries.
Fig. 171
Fig. 172
Surgical anatomy and ligation of the radial and ulnar vessels. (Bernard and Huette.)
The External Iliac Artery.
—The external iliac artery is exposed without great difficulty by a 10 Cm. incision about Poupart’s ligament, beginning near the pubic spine, extending outward and slightly upward. It will probably be necessary to double ligate and divide the superficial epigastric artery, after which the outer border of the conjoined tendon is to be recognized at the lower and inner end of the incision. The lower fibers of the internal oblique are then to be divided, the transversalis exposed and transversely divided, after which the deep epigastric artery will probably come into view. The pulsations of the external iliac will now identify it. The subperitoneal tissue should be carefully detached and the peritoneum gradually separated from the vessels and properly retracted. Beneath it the areolar tissue which helps form the sheath of the vessel must be avoided, after which the artery needle may be passed from within outward. In closing the wound the deep layers should be brought together, each by itself, in order to avoid the possibility of ventral hernia. Through this same incision both the deep epigastric and the deep circumflex arteries may be exposed ([Figs. 173], [174] and [175]).
Fig. 173
