. Abdominal hernia : its diagnosis and treatment. to the outer side ofthe sac. The sac should have been shown with smaller neck. ciitting through this, however, he will come upon the subperi-toneal fat (sometimes mistaken for adherent omentum) andthen reach the bluish-white, true hernial sac. As in other loca-tions when the true sac is opened, tliere is ahnost uniformlyfound evidence of the normal abdominal fluid and the shinysurface characteristic of peritoneum. When the skin and the superficial fascia are incised,usually the sac and its subperitoneal fat will come into the 336 ABDOMINAL HERN
. Abdominal hernia : its diagnosis and treatment. to the outer side ofthe sac. The sac should have been shown with smaller neck. ciitting through this, however, he will come upon the subperi-toneal fat (sometimes mistaken for adherent omentum) andthen reach the bluish-white, true hernial sac. As in other loca-tions when the true sac is opened, tliere is ahnost uniformlyfound evidence of the normal abdominal fluid and the shinysurface characteristic of peritoneum. When the skin and the superficial fascia are incised,usually the sac and its subperitoneal fat will come into the 336 ABDOMINAL HERNL\. wound, appearing like an encysted lipoma (fig. 183), separating the sac, it is best that this entire mass shouldbe lifted out of its bed by thumb forceps and blunt dissection,so that its neck where it passes under Pouparts ligament shallbe entirely free from its surroundings. By traction on the sac(fig. 184) and its superimposed fat. this neck may not only befreed, but it will be materially lengthened, so that when it is Fig. Sac forcibly drawn down while being ligated and cut a\va\. This after e.\amining its interiorto see that no adhesions exist. finally ligated and cut oflf it will retract within the abdominalcavity, leaving the femoral canal free of foreign tissue. Thisis absolutely essential to the subsequent permanent cure of thecase. It must be borne in mind that extreme traction mighteasily bring into the operative field either an angle of the blad-der wall to the inner side, or the deep epigastric vessels uponthe upper surface of the sac. Both of these have been seen inthis operation. SURGICAL CURE: FEMORAL. 337 The sac should be opened, and where omentum is foundadherent it should be carefully ligated, cut away, and its stumpreduced to the abdominal cavity. Adherent intestine will rarelybe found, but where it is, the adhesions must either be brokenup, or, if too firm, the adherent part may be cut out of thesac and left attached to the bowel. When
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