A Manual of the Operations of Surgery

The operation from below (Plate I. fig. 4), Sir Astley Cooper's, is thus described by Mr. Hodgson:4—"A semilunar incision is made through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of the incision will be situated near the spine of the ilium; the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscles will be exposed, and is to be divided throughout the extent, and in the direction of the external wound. The flap which is thus formed being raised, the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia which lines the transverse muscle through which the spermatic cord passes, is situated in the mid space between the anterior superior spine of the ilium and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If the finger therefore be passed under the spermatic cord through this opening in the fascia, it will come in immediate contact with the artery which lies on the outside of the external iliac vein. The artery and vein are connected by dense cellular tissue, which must be separated to allow of the ligature being passed round the former."

In comparing the two methods of operating, we find that while the latter is in some respects easier, and the vessel in it lies more superficial, it has certain disadvantages which more than counterbalance its advantages. Thus, first, the epigastric artery is very likely to be wounded. It may be said, Well, if so, the ends can be tied; but this tying is sometimes very difficult; and, as shown in Dupuytren's case of this accident, involves considerable interference with the peritoneum, and a possibly fatal peritonitis. Besides this, by cutting the epigastric you destroy an important agent which would have carried on the anastomosing circulation, and thus greatly increase the risk of gangrene. By this method, also, the artery is exposed too near to the seat of disease; and if found to be enlarged and involved in the aneurism, considerable difficulty may be experienced in reaching the upper part of the vessel. Again, ligature of the lower third or half of the vessel, which this method implies, is dangerous from the occasional high origin of the circumflex or epigastric, or both, rendering the formation of a clot much more difficult, and secondary hæmorrhage much more likely.

The circumflex iliac vein must also be remembered, as it crosses the artery from within outwards in the lower end of it, just before it goes under Poupart's ligament.

However, the method may occasionally vary with the individual case. In every case of ligature of the great vessels of the abdomen, the bowels should be carefully evacuated before the operation, and the bladder emptied. A properly managed position, with the shoulders raised and the knees semiflexed, will greatly facilitate the gaining access to the vessel.

In sewing up the wounds in the abdominal walls, advantage will be gained by putting in a certain number of stitches so deeply as to include the whole thickness of the muscles, and in the intervals between these deep ones to insert others less deeply, so as accurately to approximate the edges of the skin. This will both facilitate union and also render the occurrence of hernia less probable. This latter accident did occur in a case, otherwise successful, in which Mr. Kirby tied the external iliac.

Both external iliacs have been tied in the same patient with success, on at least two occasions, once by Arendt, with an interval of only eight days between the operations; and a second time by Tait, at an interval of rather more than eleven months.

This operation is in the great majority of cases performed for femoral aneurism, and naturally secondary hæmorrhage is a too frequent result. Wounds of these great vessels generally result in so rapid death from hæmorrhage as to give no time for surgical interference. One case, however, is recorded,5 in which the external iliac was cut in a lad of seventeen by an accidental stab, and in which Drs. Layraud and Durand, who were almost instantly on the spot, succeeded in stopping the bleeding by compresses, till Velpeau arrived, who tied the vessel above with perfect success.

Of the first twenty-two cases collected by Hodgson, fifteen recovered—a mortality of 31.81 per cent.; and of 153 in Norris's collection, including Cutter's cases, forty-seven died—a mortality of only 32.5 per cent.,—a very satisfactory result, considering the size of the vessel and the importance of its relations.

Ligature of Gluteal.—This vessel, though one of the branches of the internal iliac, approaches the surface so nearly as to be occasionally wounded. It is also, though very rarely, the subject of spontaneous aneurism. The principle of treatment and the operation to be selected in any given case, depends upon its origin, whether traumatic or spontaneous. For if traumatic, the wound must almost necessarily be accessible from the outside; the neighbouring part of the artery is probably healthy, and hence the case can be treated by the old operation, slitting up the tumour, and tying the vessel above and below the wound. When the aneurism is spontaneous, there is no guide to tell us where the aneurism may have first originated; it may be that it is high up in the pelvis, and that the visible tumour is only its expansion in the direction of least resistance, or the coats of the vessel may be extensively diseased. The only chance is ligature of the internal iliac.

1. The old operation, or ligature of the gluteal artery in the hip.

Anatomical Note.—The gluteal is the largest branch of the internal iliac, and leaves the pelvis by the great sacro-sciatic notch just at the upper edge of the pyriformis muscle. After a very short course, it divides into superficial and deep branches opposite the posterior margin of the glutens minimus, between it and the pyriformis muscles.

Very precise rules have been given to enable the operator to hit on the exact spot where the artery leaves the pelvis. These, though perhaps interesting anatomically, are quite useless in a surgical point of view, for the only reasons which could possibly induce a surgeon to cut down upon the gluteal in the living body, are the existence either of a wound of the vessel or an aneurism. In the first the flow of blood, in the second the tumour, would give sufficient guidance.

In cases of traumatic aneurism the operation should be something like the following:—A free incision should be made into the tumour, dividing it in its long direction; the contents should be rapidly scooped out, and a finger placed on the bleeding point, just at the upper corner of the sciatic notch. This will at once stop the hæmorrhage till the vessel can be secured. This sounds easy enough, and has been done several times with success. Thus, John Bell, by an incision two feet long, as he tells us in his hyperbolical language, was enabled to tie the vessel in the case of the leech-gatherer who had punctured the artery by a pair of long scissors. Carmichael of Dublin used a smaller incision, removed one or two pounds of clots, and tied the vessel, in a case of wound by a penknife.6

Now, though both of these cases were eventually successful, both patients lost during the operation a very large quantity of blood; John Bell's especially could not be removed from the operating-table for a considerable time after the operation. The period at which the great loss of blood took place was the interval after the incision was made, and before the artery was exposed to view, i.e. the interval in which the surgeon was busy dislodging the clots from the cellular membrane, the sac of the false aneurism. The procedure devised by Mr. Syme to obviate this difficulty, and which was put in practice by him in several very trying cases, is best given in his own terse description of an operation in a case of traumatic gluteal aneurism:—

"The patient having been rendered unconscious, and placed on his right side, I thrust a bistoury into the tumour, over the situation of the gluteal artery, and introduced my finger so as to prevent the blood from flowing, except by occasional gushes, which showed what would have been the effect of neglecting this precaution, while I searched for the vessel. Finding it impossible to accomplish the object in this way, I enlarged the wound by degrees sufficiently for the introduction of my fingers in succession, until the whole hand was admitted into the cavity, of which the orifice was still so small as to embrace the wrist with a tightness that prevented any continuous hæmorrhage. Being now able to explore the state of matters satisfactorily, I found that there was a large mass of dense fibrinous coagulum firmly impacted into the sciatic notch; and, not without using considerable force, succeeded in disengaging the whole of this obstacle to reaching the artery, which would have proved very serious if it had been allowed to exist after the sac was laid open. The compact mass, which was afterwards found to be not less than a pound in weight, having been thus detached, so that it moved freely in the fluid contents of the sac, and the gentleman who assisted me being prepared for the next step of the process, I ran my knife rapidly through the whole extent of the tumour, turned out all that was within it, and had the bleeding orifice instantly under subjection by the pressure of a finger. Nothing then remained but to pass a double thread under the vessel, and tie it on both sides of the aperture."

The bleeding in this case was thus rendered comparatively trifling, and the patient made a speedy and complete recovery. He returned home within six weeks after the operation.7

2. In one case, at least, the gluteal artery has been tied with success (for traumatic aneurism) just where it leaves the pelvis, without the tumour being opened. This was in the practice of Professor Campbell of Montreal. The operation was a very difficult one, and while possible only in cases seen very early, and where the tumour is very small, does not appear to have any advantage over the old method.

Cases of spontaneous aneurism of the gluteal artery should be treated by ligature of the internal iliac. Steven's and Syme's cases of ligature of the internal iliac were of this nature.

Manuals of operative surgery occasionally devote pages to the description of special operations for the ligature of such arteries as the sciatic, epigastric, circumflex ilii, and pudic. They do not require ligature, except in cases of wound either of the vessels themselves or their branches; and, according to the modern principles of surgery in such cases, the ligature should be applied to the bleeding point, rather than to the vessel at a distance above it.

Ligature of Femoral.—Under this head we practically mean cases of ligature of the superficial femoral, for the common femoral, or (as called by some anatomists) the femoral, before the profunda is given off, very rarely requires to be tied. If it is wounded, of course the bleeding point must be sought, and the artery tied above and below it, but if an aneurism on the superficial femoral renders ligature of that trunk impossible, experience teaches that ligature of the external iliac gives better results than ligature of the common femoral. Erichsen asserts that out of twelve cases in which the common femoral has been tied, only three have succeeded, the others dying from secondary hæmorrhage. The experience of the Dublin surgeons, Porter, Smyly, and Macnamara, has been more satisfactory, as in eight cases of this operation six were successful.8 A ninth case was unsuccessful. Reasons to explain the danger are not far to seek, for the numerous small muscular branches, along with the superficial epigastric, circumflex, and pudic trunks, reduce the chances of a good coagulum in the common femoral to a minimum, even without taking into consideration the shortness of the trunk before the great profunda femoris is given off. For the common femoral artery is only from one to two inches in length, and if there are some rare cases in which it is a little later in its bifurcation, there are others in which it divides nearer to Poupart's ligament.

The superficial femoral is the name given to the main trunk between the origin of the profunda, and the point at which, passing through the tendon of the adductor magnus, it receives the name of popliteal. During this long course it gives off no branch large enough or regular enough to receive a name, except one, the anastomotica magna, which rises in Hunter's canal, close to the end of the vessel, so in that respect it is peculiarly suitable for the application of a ligature. Again, in the upper part of its course, it is superficial, being covered only by skin and fascia. A short notice of its most important anatomical relations is necessary.

For the first two inches or two inches and a half of its separate existence, the superficial femoral lies in Scarpa's triangle, covered, as we said, only by skin and fascia. This triangle is formed by the sartorius and adductor longus muscles which meet at its apex, and by Poupart's ligament, which defines its base. The artery lies almost exactly in the centre of the space, and at the apex is covered by the sartorius muscle. The spot where it goes under the sartorius is the one selected for the application of the ligature. The femoral vein lies to the inner side of the femoral artery in this triangle, but their mutual relations vary with the portion of the limb; for, on the level of Poupart's ligament, the artery and vein lie side by side on the same plane, but in different compartments of their sheath; as the artery dives below the sartorius, the vein is still on the inside, but on a plane slightly posterior; while, by the time they reach Hunter's canal, the vein has got completely behind the artery. The separate compartments of the sheath in which the vessels lie are much less marked as the vessels go down the limb, the septum between the artery and the vein being in most cases very ill marked, even at the level where the ligature is applied. The anterior crural nerve, which on the level of Poupart's ligament lay outside of the artery and on a plane somewhat posterior, has divided into numerous branches before it reaches the point of ligature. One of its branches requires to be mentioned, and may sometimes be noticed and avoided during the operation, namely the internal saphenous nerve, which, first lying external to the artery, crosses it in front, reaching its inner side just before it enters Hunter's canal, where it leaves the vessel accompanying the anastomotica magna branch.

Operation of Ligature of the Femoral—Scarpa's Space.—The patient being placed on his back, and being brought very thoroughly under chloroform, the knee of the affected limb should be bent at an angle of about 120°, and supported on a pillow. Having previously ascertained the angle of junction of the sartorius and adductor, the surgeon should make an incision (Plate I. fig. 5) just over the pulsations of the vessel, in the middle line of the space, having its lower end quite over the sartorius muscle, and its upper one, at a distance from two and a half to three and a half inches, varying according to the amount of fat and muscle. The saphena vein can generally be recognised, and is almost always safe out of the way of this incision at its inner side.

The first incision should divide the skin, superficial fascia, and fat, quite down to the fascia lata. The edges of the wound being held apart, the fascia should be carefully divided, and the sartorius exposed; its fibres can generally be easily enough recognised by their oblique direction; once recognised, the fascia should be dissected from it till its inner edge be gained, the corner of which should then be turned so that it may be held outwards by an assistant with a blunt hook. The sheath of the vessels is now exposed, and after having thoroughly satisfied himself of the position of the artery by the pulsation, the surgeon should carefully raise a portion of the sheath with the dissecting forceps, and open it freely enough to allow the coats of the artery to be distinctly seen. If the parts are deep, as in a fat or muscular patient, great advantage will be gained by seizing one edge of the sheath by a pair of spring forceps, and committing it to the care of an assistant, while the operator holds the other in his dissecting forceps; there is thus no fear of losing the orifice of the sheath, which without this precaution may easily happen, from the parts being confused with blood, or the position altered by movements of the patient. Now comes the stage of the operation on which, more than on anything else, success or failure depends. A small portion of the vessel must be cleaned for the reception of the ligature, and it must be thoroughly cleaned, so that the needle may be passed round it without bruising of the coats, or rupture of an unnecessary number of the vasa vasorum by rough attempts to force a passage for it. Hence all compromises, such as blunted instruments, silver knives, and the like, are dangerous, for in trying to avoid the Scylla of wounding the artery, they fall into the Charybdis, on the one hand, of isolating too much of the vessel and causing gangrene from want of vascular supply, or, on the other, expose the vein to the danger of injury by the aneurism-needle in their attempts to force it round an uncleaned vessel.

The needle should in most cases be passed from the inner side, care being taken to avoid including the vein which is on the inner side and behind the vessel; the internal saphenous nerve, if seen, should be avoided. The needle must not be passed quite round the vessel raising it up, still less must the vessel be held up on the needle, as used to be done, as if the surgeon was surprised at his own success, but the needle should be passed just far enough to expose the end of the ligature, which must be seized by forceps and cautiously drawn through. It must then be tied very firmly and secured with a reef knot.

The edges of the wound must be brought into accurate apposition, and secured by one or two stitches. If antiseptics are used, drainage should be provided for.

From the very fact that ligature of the superficial femoral is a remarkably successful operation in causing consolidation of the aneurism and a rapid cure, there is also a corresponding danger that the limb be not sufficiently supplied with blood at first. The limb may very possibly become cold, and remain so for some hours at least after the operation. To avoid this as far as possible, it should be wrapped in cotton wadding, and very great care should be taken that it be not over-stimulated by hot applications, friction, or the like, any of which measures might very likely excite reaction, which would result in gangrene.

Complete rest of the limb and of the whole body must be enjoined; the food must be nourishing and in moderate quantity. The chief danger is from gangrene of the limb, which is especially apt to result when the vein is wounded, or even too much handled during the operation.

When properly performed, and in suitable cases, the operation is very successful. Mr. Syme tied this artery for aneurism thirty-seven times, and of these every one recovered. The statistics of Norris and Porta, who collected all the cases in which ligature of the femoral had been employed for any cause, show a mortality of somewhat less than one in four. Rabe's table up to 1869 with the additional cases collected by Mr. Barwell to 1880 gives 297 cases with 53 deaths.9 Mr. Hutchinson's table, again, of fifty cases collected from the records of Metropolitan Hospitals, shows the very startling result of sixteen deaths out of the fifty cases, or a mortality, in round numbers, of one-third.

Certain anomalies have been observed in the distribution of the femoral vessels, of some importance as affecting the possibility of applying, and the result of, ligature; such as—1. A high division of the branches which afterwards become posterior tibial and peroneal. 2. A double superficial femoral, both branches of which may unite and form the popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the artery altogether, as in Manec's case, where the popliteal was a continuation of an immensely enlarged sciatic.

In such a case the absence of pulsation in front, and the presence of increased pulsation behind the limb, ought to prevent any fruitless attempt at search.

Ligature of the Superficial Femoral below the Sartorius Muscle.—This operation, though once common in France, and though the one recommended by Hunter himself, is now comparatively little used in this country; and rightly so; for while it has no advantage over the upper position, it is at once nearer the seat of disease, and the vessel is more deeply buried under muscles, and has a more distinct fibrous sheath, which requires division.

It is, however, by no means a difficult operation, and is thus performed:—

The limb being laid as before on the outside, and slightly bent, the skin shaved and the pulsation of the artery detected, an incision (Plate I. fig. 6) must be made from the lower edge of the sartorius muscle just as it crosses the vessel, along the course of the vessel, avoiding if possible the internal saphena vein.

The sartorius when exposed must be drawn inwards. The fibrous canal filling the interspace between the abductor magnus and vastus internus is then recognised, and must be fairly opened; the artery is now seen lying in it, and over the vein which is posterior to it, but projects slightly on its outer side; the internal saphenous nerve is lying on the artery. The needle is best passed from without inwards so as to avoid the vein. The anastomotica magna is sometimes a large trunk, and has been mistaken for the femoral in this situation, and tied instead of it.

Ligature of the Popliteal.—This operation is now hardly ever performed for aneurism, ligature of the superficial femoral having quite superseded it, and it is very rarely required for wounds, from the manner in which the vessel is protected by its position.

Before the invention of the Hunterian principle of ligature at a distance, the old operation for popliteal aneurism consisted in cutting into the space, clearing out the contents of the aneurismal sac, and tying both ends of the vessel; from the depth of parts and the close connection of the popliteal vein, this operation was very rarely successful, and is now quite given up. If the vessel is wounded the bleeding point is the object to be aimed at, and is generally sufficient guide.

In cases of hæmorrhage for suppuration of an aneurismal sac, it might possibly be advisable, and there are certain cases of rupture of the artery, without the existence of an external wound, in which attempts have been made to save the limb by tying the vessel.10 From the complexity of the parts, the numerous tendons, veins, and nerves crowded together in a narrow hollow, and chiefly from the great depth at which the artery lies, any attempt at ligature is very difficult. It is least so at the lower angle of the space, where, between the heads of the gastrocnemius, the vessel comes more to the surface, but is still overlapped by muscle.

Operation.—The patient lying on his face, a straight incision (Plate III. fig. 1), at least four inches in length, should be made over the artery, and thus nearer the inner than the outer hamstring; a strong fibrous aponeurosis will require division after the skin and superficial fascia are cut through, the limb is then to be flexed, and the tendons drawn aside with strong retractors; fat and lymphatic glands must next be dissected through, and then the vein and artery, lying on a sort of sheath of condensed cellular tissue, are seen, the vein lying above the artery and obscuring it. The vein must be drawn to the outside, and the thread passed round the artery, which lies close to the bone, on the ligamentum posticum of Winslowe.

It is a very difficult subject to decide what operations should be described in a work of this character, on the vessels of the leg and foot. A very large number of distinct methods of operations on the various parts of the three chief arteries of the leg have been described by surgeons and anatomists, but specially by the latter.

The fact is, however, that these complicated procedures are rarely required, for aneurisms of the arteries of the leg and foot are almost unknown, while in cases of wound of the vessel, or rupture resulting in traumatic aneurism, the proper treatment is not to tie the vessel higher up, but by dilating the wound and clearing out the clots, if required, to secure the bleeding point, and tie the vessel above and below.