. Abdominal hernia : its diagnosis and treatment. ssummit and a small portion of its posterior wall, but not itsanterior wall. When this distribution of peritoneum is considered it willbe readily understood how any one of these organs may pro-trude in either one of three conditions: (i) It may become apart of the hernial contents, in a prefonned sac—intra-peri-toneal (fig. 156). (2) It may protrude independently, with-out any serous covering—extra-peritoneal (fig. 157). (3) Itmay be dragged down in the formation of the hernial sac and SIGMOID: C^CAL: BLADDER. 279 have a partial peritoneal cove
. Abdominal hernia : its diagnosis and treatment. ssummit and a small portion of its posterior wall, but not itsanterior wall. When this distribution of peritoneum is considered it willbe readily understood how any one of these organs may pro-trude in either one of three conditions: (i) It may become apart of the hernial contents, in a prefonned sac—intra-peri-toneal (fig. 156). (2) It may protrude independently, with-out any serous covering—extra-peritoneal (fig. 157). (3) Itmay be dragged down in the formation of the hernial sac and SIGMOID: C^CAL: BLADDER. 279 have a partial peritoneal covering, and become both intra- andextra-peritoneal. As previously stated, protrusions into a preformed sachave not been considered by the author to constitute eithersigmoid, Ccccal, or bladder hernia, because they are easilyreduced with the other hernial contents, quickly recognized,and not liable to accidental injur\. Sigmoid and Caecal Hernia.—In these hernia the bowelmay be dragged down by a sac of peritoneum previously Fig. 157. Sac wall. Hernial sac in front of caecum. No peritoneal covering on posterior wall of bowel. formed and containing other folds of the large, or many loopsof small intestine and omentum. The posterior sac wall is thenthe normal peritoneal covering of the anterior surface of eitherthe c?ecum or sigmoid, as the case may be. If the operator,fortunately, opens into the sac high up, near the internal ring,he will usually discover the true state of affairs and avoidinjury to the bowel, either by tying off a portion of it with hissac ligature, or by rudely tearing it away from its deep attach-ments and perhaps lacerating the intestinal wall in a mannerthat would be difficult to repair. If, on the contrary, he opens 280 ABDOMINAL HERNIA. into the fundus or lower portion of such a protrusion he maydiscover too late that he has opened directly into the bowel. In operating upon these extremely difficult cases unusualcaution is necessary throughout the entir
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