Operations for the ligature of the internal iliac artery. — The method adopted in this operation by Stevens, by whom the artery was first tied, and that recommended by the ma jority of writers, is similar in principle to the first plan of Abernethy for the external iliac, and differs from it only in the length of the incision, which, according to Guthrie, should be five inches, beginning about half an inch above I'oupart's ligament and about the same distance to the outside of the inner ring; it should be nearly parallel to the course of the epigastric artery, but a little more to the out side, in order to avoid it and the spermatic cord, and have a gradual inclination inwards toward the external edge of the rectus muscle : according to Hodgson the centre of it should be nearly opposite the superior anterior spinous process of the ilium. The aponeurosis of the external oblique, and the internal oblique and tranversalis muscles having been divided with the same precautions to avoid the peritoneum, as in the other case, the fascia transversalis is to be torn through at the lower and outer part, so that the fingers may be passed outward towards 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 finger inwards and upwards, until passing over the psoas muscle the ex ternal iliac artery is discovered by its pulsation. This is then to be traced upward and inward toward the spine, where the origin of it and the internal iliac from the common iliac trunk will be felt. The artery is to be traced down ward from its origin and separated with care from its connections, and more especially the vein. The sides of the wound should now be separated and kept apart with curved spatula in order that the surgeon may, if possible, see the artery, and have sufficient space for passing the ligature. Great care must be taken to avoid every thing but the artery ; the peri toneum which covers, and the ureter, which crosses it, must be particularly kept in mind ; the latter may be separated with ease, and usually accompanies the former as it is being detached from the artery. The situation of the external iliac artery and vein, which have been crossed to reach it, must be always recollected, and, if possible, they should be kept out of the way and guarded by the finger of an assistant.* This method has in this case a recommendation, which it does not possess for the other iliaes, viz. that, as it is necessary in tying the internal iliac to descend more or less into the pelvis, it is desirable that the external wound should be as near as possible to the aperture of the cavity, but the danger to the peritoneum must be even greater because of the greater extent to which it must be separated, and the closer attachment of it to the ten dinous than the muscular structure of the abdominal wall. It, therefore, seems to me a question whether even in this case the line of incision here recommended should be adopted, and whether it would not be better to have recourse to that either of Roux or Cooper. Of the two perhaps the former may be best adapted to the internal iliac for the reason just assigned ; though, if the inferior extremity of the incision he not carried beyond the middle of Poupart's ligament, difficulty must be ex perienced in exposing the vessel and passing the ligature; therefore here again I am dis posed to prefer the semilunar line of Cooper, only not brought so close to the crural arch as for the external iliac, and prolonged, as di rected by Velpeau, two inches at its external extremity.
It is recommended to pass the ligature from within outward because the internal iliac vein is posterior to the artery ; this appears to me, however, not the most judicious plan, by it the point of the needle must he first carried out ward and then forward and inward in order to pass round the vessel : now the external iliac vein is immediately external to and crossed by the artery ; the junction of the two iliac veins is also external to the artery, and the internal one, though posterior, is at the same time ra ther external to it. In such a ease the course
to be pursued must be very much influenced by the convenience of the moment ; but it would seem the better plan, where a choice can be made, to pass the needle first backward between the artery and the external iliac vein, and then inward behind the artery toward the pelvis, by which plan the veins will be more surely avoided, and more space will be ob tained for seizing the ligature.
In this as well as every operation upon the iliac arteries, the spermatic vessels must be kept in mind, inasmuch as they require atten tion as much as the ureter ; they are usually, however, like it, removed with the peritoneum. Velpeau suggests the possibility of rupturing the ilio-lumbar artery in isolating the internal iliac, and the risk ought not to be overlooked.
Ligature of the primitive iliac artery.—Any of the methods recommended, whether for the internal iliac or the external at a high point, will answer for the ligature of the primitive iliac. Guthrie gives the preference to that upon Abernethy's first plan in this as in the case of the internal iliac ; but it appears to me that here, at all events, the method of Roux or the modification of Cooper's operation is to be preferred ; for, beside that there does not exist in this case the reason for approximating the line of incision to the. aperture of the pelvis, which applies to the internal iliac artery, the situation of the ancurismal tumour in front must render the direct line of incision less convenient than a lateral one, and by the adoption of the for mer there must be incurred a great exposure of the peritoneum without a commensurate advantage; the necessity also of stripping the membrane from all or a great part of the front of the aneurism, incurred by this plan, must be very objectionable. The length of incision recommended by Guthrie is five inches at the least, and may be required of even greater extent; thus Mott was obliged to extend it in his case upward and backward, about half an inch within the ilium, to eight inches : he adopted the principle of Cooper, commencing his first incision " just above the external ab dominal ring, and carrying it in a semicircular direction half an inch above Poupart's liga ment until it terminated a little beyond the anterior superior spinous process of the ilium, making it in extent about five inches." It is likely that a longer incision may be necessary in this method when applied to the primitive iliac than in that recommended by Guthrie ; the greater length of the external incision is doubtless an objection of secondary impor tance; but it is probable that, when the pri mitive artery is to be tied, little will be gained by commencing the incision so low as was done by 'Mott, and that it would be more ad vantageous to carry it upward rather than downward ; such appears to have been the design of Crampton in the operation per formed by him for the ligature of the primitive iliac, in which the line of incision was curved, concave toward the umbilicus, and extended from the anterior extremity of the last rib down ward beyond the superior anterior spinous process of the ilium, and since unnecessary division of the abdominal parietes is of course to be avoided, and the leaving them entire at the lower part must be attended with two good results, viz. avoidance of the aneurism and less subsequent danger of pecuniary protrusion, I cannot but regard this plan as o desirable addition to the methods of proceeding when the primitive iliac is the vessel to be tied. In passing the ligature the difference of the relation between the vein and artery of the opposite sides is to be borne in mind, the former being external to the artery on the right and internal on the left, on both sides however being upon a posterior plane.