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gastro-intestinal canal. Inflammatory infections of the peritoneum are therefore almost always secondary to lesions of the viscera. The peritoneal lymph sac is brought into direct communication with the subperitoneal lymph vessels of the diaphragm through stomata which open upon the peritoneum covering the abdominal surface of that muscle. With the object, therefore, of diminishing septic absorption after operations for peritonitis, the patient is kept in the half-sitting posture, and pelvic drainage is established. The healthy peritoneum, in virtue of the vital action of its endothelial cells, is endowed with great absorptive properties, and, when irritated,
FIG. 1102.-LATERAL ASPECT OF TRUNK, SHOWING SURFACE
R.L. Right lung.
R.K. Right kidney.
has the power of throwing out an abundant exudation, the cellelements of which are actively phagocytic.
The reflection of the peritoneum and its relations to the various organs have been fully described in the section on the Digestive System.
The attachment of the transverse mesocolon to the posterior abdominal wall is at the level of the first lumbar vertebra, and lies, therefore, a little above the infracostal plane. The attachment, which ascends slightly as it passes from right to left, crosses the right kidney, the descending part of the duodenum, and the head of the pancreas, after which its attachment follows the anterior border of the pancreas. The peritoneal subdivision above this attachment is roofed in by the diaphragm, and includes the superior part of the great sac, and, behind it, the larger portion of the omental bursa. The organs related to this area of the peritoneum are the liver, along with the bile-ducts and gall bladder, the stomach and part the duodenum, the spleen, the pancreas, the upper parts of the kidneys, and the suprarenal glands Suppuration connected with any of these organs is liable to spread upwards under the cupola of the dia phragm, producing what is known as subphrenic abscess.
The attachment of the mesentery of the small intestine extends from the left side of the second lumbar vertebra downwards to the right iliac fossa. The attachment may be mapped out on the surface by drawing a line from a point on the transpyloric line. one inch to the left of the median plane, to the mid-point of a line draw horizontally between the right anterior superior iliac spine and the median plane
Subdivisions of the Peritoneal Cavity. From the surgical point of view the peritoneal cavity may be arbitrarily divided into four great subdivisions: namely a supracolic, a right infracolic, a left infracolic, and a pelvic. All these subdivisions communicate freely with one another behind the anterior abdomin wall, as well as on each side, along the gutter-like channels in the loins is along these gutters that pus readily makes its way from the upper part
FIG. 1103.-ANTERIOR ASPECT OF TRUNK, SHOWING SURFACE TOPOGRAPHY OF VISCERA.
M.C. Mid-clavicular line.
Common iliac artery.
External iliac artery.
I.V.C. Inferior vena cava.
the abdomen along the lumbar regions into the iliac regions, and thence into the pelvis; and, on the other hand, the pus may ascend from the pelvis along the same channels, especially when the patient is in the recumbent posture.
The highest (subphrenic) region of the supracolic compartment is further sub-or divided into a right and left portion by the falciform ligament.
The omental bursa may be looked upon as a diverticulum of the first-mentioned subdivision.
The subphrenic lymph plexus communicates, by means of lymph vessels which pierce the diaphragm, with the subpleural plexus on its superior surface; hence pus confined under tension in either of these spaces is liable to give rise to secondary infection of the corresponding pleural cavity. By adhesions of the transverse colon and greater omentum to the anterior abdominal wall, the supracolic subdivision of the peritoneal cavity may become more or less completely shut Liv off from the rest of the abdomen. Suppuration in the right half of the phrenico-de colic subdivision is generally secondary to leakage from an ulcer of the first part of the duodenum or to disease of the gall-bladder and bile-ducts; while the left the half of the space is more usually infected from the stomach. The best method of draining the supracolic subdivision of the peritoneal cavity is to pass a tube through the hepato-renal pouch of Morrison. The entrance to this pouch lies lateral to the gall-bladder between the inferior margin of the liver above and the right flexure of the colon below. The bottom of the pouch is formed by the reflection of the h peritoneum from the superior part of the kidney on to the fascia transversalis covering the aponeurosis of origin of the transversus abdominis muscle below the tip ofer the twelfth rib. To drain it, a tube is introduced into it either from the wound in the anterior abdominal wall, or, still better, through a puncture opening made through the loin lateral to the kidney, in the angle between the twelfth rib and the lateral border of the sacro-spinalis muscle. Another drainage route is by at tube passed from the wound in the anterior abdominal wall into the omental bursa, through either the gastro-hepatic ligament or the great omentum.
The right infra-colic subdivision lies above and to the right of the mesentery of the small intestine. It is bounded, above, by the right and middle two-thirds of the transverse colon and the corresponding part of its mesentery, while laterally it is limited by the cæcum and ascending colon. At its right inferior angle are the ileo-cæcal junction and the vermiform process; at its right upper angle is the right flexure of the colon, while at its left upper angle is the inferior part of the duodenum, crossed by the superior mesenteric vessels.
The organs related to this subdivision are, in addition to the parts of the large intestine already mentioned, coils of small intestine, the inferior third of the right kidney, the right ureter, the inferior half of the descending and the horizontal part of the inferior portions of the duodenum.
Suppuration in connexion with the organs in this area involves more especially the right lumbar region, and may extend upwards along the colon into the subdiaphragmatic region, or downwards into the pelvis minor. To drain this region a tube is introduced into the right lumbar region either through the anterior abdominal wall or through a stab-wound in the loin lateral to the ascending colon.
The left infra-colic subdivision, which lies below and to the left of the mesentery, narrows as it passes upwards and reaches to a higher level than the right infra-colic subdivision. Inferiorly, it is directly continuous at the superior aperture of the pelvis with the peritoneal cavity of the pelvis minor. Above, it is bounded by the left third of the transverse colon and its mesentery, and, still more posteriorly, by the inferior surface of the body of the pancreas; laterally it is bounded by the descending and iliac portions of the colon. At its right upper angle is the duodenojejunal flexure, lying immediately to the left of the vertebral column, in the angle between it and the inferior surface of the pancreas. At its left superior angle is the left flexure of the colon, while at its left inferior angle is the junction of iliac with pelvic colon. This subdivision of the peritoneal cavity, in addition to containing the majority of the coils of the small intestine, is related to the inferior third of the left kidney, the left ureter, the lower part of the abdominal aorta and vena cava, and the inferior mesenteric and common iliac vessels.
Drainage of this
subdivision may be established through the left loin, or by a tube introduced down to the bottom of the pelvis, namely, into the recto-vesical pouch in the male, and into or through the recto-vaginal pouch (pouch of Douglas) in the female.
On account of the oblique manner in which the mesentery proper is attached to the posterior abdominal wall, it follows that in order to examine the organs related to the right infra-colic subdivision of the abdomen, the coils of small intestine should be displaced downwards and to the left, while to investigate the left infra-colic subdivision they should be carried upwards and to the right.
Liver. The anterior margin of the liver, as it crosses the costal angle, can readily be determined by palpation and light percussion; it passes from the eighth left to the tip of the tenth right costal cartilage, and crosses the median plane at the level of the transpyloric line. In the mid-clavicular line it reaches down to a point a little below the most inferior part of the tenth right costal cartilage. Above the left costal margin the anterior margin passes upwards and to the left to join the left border of the liver at the fifth interspace in the mammary line. The highest part of the liver, which corresponds also to the highest part of the right arch of the diaphragm, reaches, during expiration, to the level of the fourth intercostal space in the mammary line. To the right of the median plane the superior surface of the liver is too far removed from the anterior wall of the chest, and overlapped by too thick a layer of lung substance, to be accurately determined by percussion. Behind the sternum the superior surface reaches to the level of the sixth chondrosternal junctions. To the left of the median plane the superior limit of the liver cannot be determined by percussion since it merges into the cardiac dulness. The base or right lateral surface extends from the level of the seventh to the level of the eleventh rib in the mid-axillary line and is separated by the diaphragm from the lower part of the right lung and pleura.
The falciform ligament of the liver lies, as a rule, a little to the right of the median plane.
The anterior surface of the liver may be reached through a median incision, extending downwards from the xiphoid process, or by an oblique incision, a finger's breadth below and parallel to the right costal margin. To obtain free access to the superior surface the eighth and ninth costal cartilages must be resected; the seventh cartilage should, if possible, be avoided; otherwise the pleural cavity may be opened into. Division of the round and falciform ligaments allows of greater downward displacement of the liver. To reach the upper part of the lateral surface of the right lobe, portions of the seventh and eighth ribs should be resected in the midaxillary line, and both the pleural and peritoneal cavities must be traversed.
Gall-Bladder.-The relation of the fundus of the gall-bladder to the surface of the body is subject to considerable variation. Normally it is situated behind the angle between the ninth costal cartilage and the lateral border of the right rectus; exceptionally, it is pendulous and suspended from the liver by a more or less distinct mesentery; or it may be elongated and drawn downwards by adhesion. to the duodenum or colon. When displaced downwards it is liable to be mistaken for a movable kidney, but may be distinguished from that by the fact that although may be pushed backwards into the lumbar region it returns at once to its habitual position, immediately behind the anterior abdominal wall, as soon as it ceases to be manipulated.
The cystic duct is enclosed in the right extremity of the superior border of the gastro-hepatic ligament. It is about an inch and a half in length, is sharply bent upon itself close to its origin at the neck of the gall-bladder. It joins the hepatic duct at a very acute angle. The passage of a probe along the normal duct is rendered difficult by the marked flexure at its commencement, as well as by the folded condition of its mucous membrane; hence also the frequency with which calculi become impacted at the neck of the gall-bladder. In excising the gall-bladder, it is an advantage to ligature and divide the cystic artery and duct before proceeding to detach the organ from the inferior surface of the liver.
The bile-duct, about three and a half inches in length, lies, in its superior third, close to the right free border of the gastro-hepatic ligament. When cutting into this, the most accessible part of the duct, it should be drawn forwards by the finger introduced behind it, through the epiploic foramen; the portal vein, which state must be avoided, lies posterior and a little to the left of the duct. The middle third of the duct lies a little to the right of the commencement of the gastro-jace duodenal artery behind the superior part of the duodenum about a finger's breadth argu from the pyloro-duodenal junction. The inferior third of the duct, which passes downwards and to the right, is intimately related to the pancreas; in about two out of three instances it is so embedded in the posterior aspect of its head that it cannot be freed by blunt dissection. Close to its termination the duct is joined by the main pancreatic duct of Wirsung, the two opening separately, but close together, at the bottom of a diverticulum, which pierces the wall of the duodenum obliquely, and opens at the summit of a small papilla situated at the inferior part of the medial wall of the descending part of the duodenum, about four inches from the pylorus. When a calculus becomes impacted in the ampulla there is retention of the pancreatic as well as of the biliary secretion. Frequently, however, the gland possesses an accessory pancreatic duct (duct of Santorini) which opens into the duodenum at a higher level than the main duct, with which it also communicates. A calculus in the ampulla may be reached either by opening the duodenum from the front (trans-duodenal route), or by freeing the duodenum and gaining access to the duodenum from behind (retro-duodenal route). In the latter instance an incision is made, lateral to the right border of the descending part of the duodenum, through that portion of the peritoneum which passes upwards and to the right from the superior layer of the transverse mesocolon, over the superior part of the pars descendens of the duodenum on to the anterior surface of the right kidney. By blunt dissection, directed medially, behind the duodenum, that organ, along with the adjacent part of the head of the pancreas, can be separated from the kidney and vena cava, and folded over towards the left like a door on its hinges. In freeing the bile-duct from the posterior aspect of the head of the pancreas a vein of considerable size will be encountered; this vein, which returns the blood from the pancreatic-duodenal system of arteries, lies close to the bile-duct as it ascends behind the head of the pancreas to open into the commencement of the vena porta. Of the lymph glands related to the bile passages it is to be remembered that one lies at the neck of the gall-bladder, another at the junction of the cystic and hepatic ducts, while a third lies close to the termination of the bile-duct. When these glands are enlarged and indurated, care must be taken not to mistake them for impacted gall-stones.
Stomach. The stomach lies almost entirely within the left half of the epigastric region and in the left hypochondriac region. The cardiac orifice, which lies 1 in. below and to the left of the oesophageal opening in the diaphragm, is about 4 in. from the surface, and corresponds, on the anterior surface of the body, to a point over the seventh left costal cartilage 1 in. from the median plane. The pylorus, which is generally partly overlapped by the anterior margin of the liver, lies in, or a little to the right of the median plane; when the stomach. is empty it generally lies in the median plane, when distended it may reach two! or even three inches to the right of the median plane. Passing from the superior t the inferior border of the pylorus opposite its junction with the duodenum is the anterior pyloric vein of Mayo. This vein affords a useful visible guide to the position of the pylorus. Another guide is furnished by the ring-like thickening of the pyloric sphincter which projects into the commencement of the duodenum (like the cervix uteri into the vagina), and can be readily palpated through its thin wall. The pyloric portion of the stomach is practically bisected by a horizontal plane which passes through the abdomen at the level of a point midway between the jugular notch of the sternum and pubic symphysis (Addison); it lies, there fore, three to four inches below the infra-sternal notch, midway between it an the umbilicus, opposite the first lumbar vertebra. The highest part of the fundus of the stomach corresponds to the left vault of the diaphragm, and lie at the level of the fifth rib in the mammary line, a little above and behind the