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artery can be felt about an inch and a half above the tuber ischii. The ridge formed by the falciform process of the great sacro-sciatic ligament is below the artery. Divide the obturator fascia which covers the artery, and pass the ligature, avoiding the veins and the pudic nerve.
The pudic nerve is situated internally to the artery, and its branch, the perineal nerve, runs below the artery.
EXTERNAL ILIAC ARTERY.—Place the subject on the back, inclined to the opposite side, and slightly flex the hip-joint.
The surface guide is the lower part of the line given as the guide to the common and external iliac arteries.
Begin an incision a little internal to and an inch above the middle point of Poupart's ligament, and continue it upward and outward four inches. The incision should extend nearly parallel to Poupart's ligament, but slightly more concave upward. Divide the skin and fascia. Divide on a director the aponeurosis of the external oblique, the internal oblique muscle, and the transversalis muscle. Divide the transversalis fascia to the extent of the wound. Separate the peritonæum and subserous fat upward and inward from the iliac and psoas fasciæ. The artery is found at the inner border of the psoas muscle. Pass the needle from within outward to avoid the vein, which is situated internally on a lower level. Avoid the genital branch of the genito-crural nerve, and apply the ligature about two inches above the level of Poupart's ligament.
DEEP EPIGASTRIC ARTERY.—Place the subject on the back.
The surface guide to the course of the artery is the line of the iliac arteries.
Make an incision three inches long one inch above and parallel to Poupart's ligament. The incision should have its middle point over the course of the artery. Divide the integument and fascia, the ароneurosis of the external oblique, and a few fibers of the internal oblique and transversalis muscles. Di. vide on a director the transversalis fascia to the extent of the wound. The artery will be seen extending in the direction of the umbilicus. Separate the veins, and pass the needle.
The deep circumflex iliac may be secured through the same wound.
FEMORAL ARTERY.—Place the subject on the back. Semiflex the knee, and rotate outward the hip-joint slightly flexed.
The surface guide to the artery is the upper two thirds of a line drawn from a point midway between the anterior superior spinous process of the ilium and the symphysis pubis to the adductor tubercle on the inner condyle of the femur.
1. Common Femoral.-Begin an incision one half inch above Poupart's ligament, and continue it downward three inches in the line of the artery. Divide the integument and superficial fascia, avoiding the lymphatic glands. Feel Poupart's ligament, and divide on a director the fascia lata, which is attached to its lower border. The sheath of the vessels is now exposed, and should be opened one half inch below Poupart's ligament. Pass the needle from within outward, to avoid the vein which is inclosed in a separate compartment of the sheath just internal to the artery.
2. Superficial Femoral in Scarpa's Triangle.Three inches below Poupart's ligament begin an incision, and extend it downward three inches in the line of the artery. Divide the integument and superficial fascia, avoiding the internal saphenous vein. Divide the fascia lata, and recognize the sartorius muscle by its fibers extending downward and inward. Locate the artery where the sartorius and the adductor longus muscles meet. Separate and retract outward the sartorius muscle. Pass the needle from within outward, remembering that the vein is behind as well as internal, and hence directing the point of the needle toward the artery.
3. Superficial Femoral in Hunter's Canal.—Begin an incision in the middle of the thigh, and extend it downward four inches in the line of the artery. Di. vide the integument, superficial fascia, and the fascia lata. Recognize the sartorius muscle by its fibers extending downward and inward. Separate and retract inward the sartorius to expose the dense fascia forming the roof of Hunter's canal. Search for a branch of the artery which perforates this fascia to locate the artery. Divide the fascia over the artery. Retract outward the long saphenous nerve.
Pass the needle from without inward to avoid the vein which is in contact externally and posteriorly with the artery.
The femoral artery may divide in the upper part of its course, or give off its branches irregularly. It has been found situated posteriorly to its usual
PROFUNDA FEMORIS . ARTERY.—Place the subject as if for ligation of the femoral artery.
Begin an incision one inch below Poupart's ligament, and extend it downward three inches in the line of the femoral artery. Uncover the femoral artery and find on its outer side, or posteriorly, the origin of the profunda femoris. Avoid the profunda vein which is situated in front of the artery. Pass the ligature around the artery about three quarters of an inch from its origin.
POPLITEAL ARTERY.—Turn the subject on the abdomen.
The surface guide is a line drawn from a point one inch internal to the upper angle, to the lower angle of the popliteal space.
1. Above the Knee-Joint.—Begin an incision at the upper part of the popliteal space and extend it down. ward four inches, following the course of the artery. Divide the integument and fascia. Expose the fleshy fibers of the semimembranosus and retract the muscle inward. Tease a way through the areolar tissue, until the sciatic nerve is encountered. Internal to the nerve and nearer the femur, the vein resting upon the artery will be found. The artery is situated internally to the vein resting upon the femur. Retract the nerve and vein outward, and pass the needle from without inward.
2. Below the Knee-Joint.—Make an incision four inches long, extending in the course of the artery to the lower end of the line drawn as the surface guide. Divide the integument and fascia, avoiding the external saphenous vein. Tease a way through the areolar tissue between the heads of the gastrocnemius muscle, until the posterior tibial nerve is uncovered. External and deeper in the tissues, the popliteal vein, resting on the artery, is to be found. The artery is situated externally beneath the vein resting upon the popliteus muscle. Retract the nerve and vein inward, and
the needle from within outward. POSTERIOR TIBIAL ARTERY.—Turn the subject on the back. Slightly flex the knee and hip joints, and rotate outward to make the limb rest upon its outer surface.
The surface guide is a line drawn from the lower angle of the popliteal space, to a point one half inch posterior to the inner malleolus.
1. In Middle of Leg.–Make an incision four inches long, parallel to and one inch posterior to the inner border of the tibia. Divide the integument and fascia, avoiding the internal saphenous vein. The inner border of the gastrocnemius can be seen resting upon the soleus. Cut through the muscular and tendinous fibers of the soleus in the line of the primary incision, until the deep fascia is reached. Separate the soleus and retract it outward, the muscle being made lax by extending the ankle-joint. Divide on a director the deep fascia when the artery may
Retract the nerve outward, and pass the needle from without inward, avoiding the venæ comites.
2. Posterior to Inner Malleolus.-Flex the anklejoint. Make an incision three inches long, midway between the inner border of the tibia and the tendo Achillis. The incision should extend down to the level of the lower end of the internal malleolus. Di. vide the integument and superficial fascia. Divide on a director the deep fascia. Separate the tissues, to uncover the artery external to the tendon of the