124 EXERCISE XX 



Obs. 92. VI. Operation. Eeopen abdominal wound. Standing on the prepara- 



fecretion!^ *^^^'^ ^^^^* ^^^^' ^"* ^^^^ *^® cartilaginous xiphoid, gently raise the right 



median lobe (cystic lobe) of the liver, and make out the pylorus, best 

 recognized by feeling the thickness of the muscular wall. 



Retract laterally, with a pair of heavy hook-weights, upper and middle 

 parts of the right edge of the abdominal wound (text-fig. 42). Retract 

 upwards the right median hepatic lobe with a clip-weight. Where 

 pancreas and duodenum cohere, lift the duodenum somewhat and draw it 

 over to the preparation's left ; this brings into full view the right (deeper) 

 aspect of region of cohesion between the gland and duodenum. Make out 

 common bile duct. It is easily found, descending from the liver to reach 

 the pancreatic edge of duodenum; it will probably have bile visibly 

 tinging it, making its recognition easier. Follow bile duct sloping over 

 the pancreas in the duodenal omentum ; it becomes less clearly demarcated 

 closer to the duodenum, but in fact continues without deviation its 

 course to enter it. Attach to the duodenum, about 1 cm. below the point 

 where bile duct should reach it, a clip-weight, so as to keep duodenum well 

 drawn over towards preparation's left. At a point fully 2 cm. below the 

 place where bile duct should enter duodenum, begin to separate the 

 pancreatic border of the duodenum from' the pancreas, by tearing the 

 peritoneum and connective tissue cautiously with fine forceps. Double 

 ligate with thread all vessels met with in doing this. The attachment 

 between the gut and the gland is several mm. thick. When a separation 

 has been made through its thickness, pass a double-string ligature, ligate 

 each string separately, and sever the gut with a scissor-cut between, 

 avoiding wounding mesenteric vessels. Leave the upper-string ligature 

 long, and while your colleague draws on it so as to pull the duodenum 

 somewhat away from the pancreas to which it is attached, proceed 

 to separate duodenum from pancreas by tearing connective tissue piece- 

 meal and doubly ligating and cutting in succession all vessels as before. 

 In effecting the separation always spare pancreatic tissue, if need be at expense 

 of duodenal, the pancreatic, not the duodenal, being important to your observa- 

 tions. Working upwards, i. e. towards pylorus, in this way progress is soon 

 made towards the entrance of the common bile duct. Before this is reached 

 the pancreatic duct itself is met, usually 2 mm. or so below the bile duct. 

 The pancreatic duct is rather larger than the blood-vessels met with in its 

 immediate neighbourhood ; avoid mistaking it for an empty vein or large 

 lymphatic. Place around it a loose thread ligature, leaving room to open the 

 duct on the duodenal side of the ligature. Pass and tie another ligature 

 on the duct as close as possible to duodenum. Snip obliquely half through 



