Part 26

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.

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.