of the panniculus is at once apparent. Only a very moderate amount of manipulation is necessary to separate the fat from the sac, because the manipulations are conducted from the depth of the wound toward the surface, and the depth of the wound is firmly fixed. The transversalis fascia, though thin and attenuated, is sufficient to prevent any reasonable manipulations from tearing into the sac. As the hand approaches the surface, diverticulae are immediately recognized, and the dissection carried around them. Using the hand in the wound as a guide, the skin incision may be safely and rapidly completed so as to encircle the prominence of the hernial protrusion, and remove a liberal amount of the skin on its summit, without leaving large concave side walls of fat which tend to form dead spaces when sutured. The neck of the sac is cleared of fat as far up as fibres of the transversalis fascia are clearly visible and the sac opened, the contents liberated and returned to the abdominal cavity. It is important to be sure that the intraperitoneal aspect of the ring is absolutely free from adhesions. The sac is then amputated at the highest point at which the fibres of the transversalis are clearly marked. The stump left is usually about three-quarters of an inch long. This tissue plane, consisting of the peritoneum and transversalis fascia is then overlapped as in the Mayo operation and secured by mattress sutures. (Figs. 10, II, 12.) The inner margins of the sheaths of the recti are now incised from a point about half way between the ensiform and the umbilicus to a point well below the first transverse line below the umbilicus. The mesial edges of these incisions are united. by a continuous stitch, thus adding a layer to the coverings of the umbilical region. (Figs. 13, 14, 15, 16.) The recti are then freed from their beds and overlapped in the mid-line, retained by mattress sutures passed as near the middle of the muscle belly as is convenient, and aided by interrupted sutures in the free edge of the upper muscle. The anterior sheath is closed in the usual manner, and buried sutures are placed in the fat to carefully close all dead spaces. (Figs. 17, 18.) In closing the skin, 7 FIG. 13.-Diagrammatic representation of incisions in rectus sheath. FIG. 14. Cross-section, above or below, showing incision in inner margin of anterior rectus sheath and suture of inner margins together. (Diagrammatic.) FIG. 15.-Same as Fig. 14. Cross-section at the umbilicus. Diagrammatic.) FIG. 16.-Plan view (diagrammatic). Sutures of mesial edges of anterior rectus sheaths completed. |