THE ABDOMEN 9t9 



pailcreatico-duodenai aud right gastro-epiploic ; and (3) right and left hepatic. 

 The right hepatic branch will be found to give off the cystic artery, which 

 divides into superior and inferior branches. It is at this stage that the 

 inferior pancreatico-duodenal artery is to be studied. 



In dissecting the foregoing arteries, the following groups of lymphatic 

 glands are to be noted : (i) the coeliac glands surrounding the coeliac 

 axis; {2) the gastric glands arranged in two sets — superior, along the 

 small curvature of the stomach, and inferior, along the great curvature ; 

 (3) the pancreatic glands along the superior border of the pancreas ; (4) the 

 splenic glands near the hilum of the spleen ; and (5) the hepatic glands 

 within the gastro-hepatic omentum. The veins corresponding to the arteries 

 are to be preserved, if possible, in connection wth the portal system. 



The vena portae is to receive careful attention. Its mode of formation behind 

 the neck of the pancreas is to be noted, and its mode of termination at the right 

 extremity of the pprtal fissure of the liver, where it presents the portal sinus, 

 is to be shown, with the cystic vein joining its right branch. The sources from 

 which the vena portae receives its blood should be thoroughly mastered. The 

 common bile-duct is next to be studied. Its formation by the union of the 

 hepatic duct with the cystic duct is to be dissected, and the hepatic duct itseJt 

 is to be shown as formed by the union of two ducts, one issuing from the right, 

 cind the other from the left, lobe of the Uver. The duct is to be followed down 

 in front of the foramen of Winslow, behind the first part of the duodenum, 

 and between the head of the pancreas and the second part of the duodenum 

 on their posterior aspect, to about as low as the junction of the upper two- 

 thirds and lower third of the second part. Its mode of termination in the 

 interior of the second part will fall to be noted when the duodenum is opened 

 for inspection. 



The liver is now to be removed, in doing which the inferior vena cava 

 should be ligatured below it, ani then divided. It must also be divided 

 above the liver, close to the diaphragm. The viscus is then to be thoroughly 

 studied in all its aspects, and so also is the gall-bladder, the interior of which is 

 to be examined to display the reticulated mucous membrane. An effort should 

 be made at this stage to display the right and left pneumogastric nerves as 

 they enter the abdomen through the oesophageal opening of the diaphragm. 

 The right nerve may be followed to the posterior surface of the stomach, 

 and the left to the anterior surface. The stomach, duodenum, pancreas, 

 and spleen are then to be removed en masse, the oesophagus having been 

 previously tied below the seat of divasion. These organs are now to be care- 

 fully studied. After washing out the stomach and duodenum, they are to 

 be opened and their interior examined. The main pancreatic duct, or duct of 

 Wirsung, is to be shown by dissecting the pancreas from behind, and an effort 

 should be made to find the small pancreatic duct, or duct of Santorini, in the 

 head of the gland. The junction of the duct of Wirsung with the common 

 bile-duct in the duodenal wall is to be displayed, and the common internal 

 opening of the two ducts is to be examined. The spleen is to be studied, 

 and sections of it should be made and washed, with pressure, under a stream 

 of water, in order to remove the pulp, and show the trabecular framework. 



Posterior Wall of the Abdomen. 



The prevertebral sympathetic plexuses, namely, the epigastric or solar 

 and hj'pogastric, with their secondary offshoots, are to be carefully dissected. 

 The dissector will find the great splanchnic nerve piercing the cms of 

 the diaphragm, and it will guide him to the semi-lunar gangUon. These 

 gangUa, two iu number, lie at either lateral pole of the solar plexus, close to 

 each suprarenal capsule, that of the right side being under cover of the inferior 

 vena cava. The lower part of each ganghon will be found to be semi-detached 

 as the aortico-renal ganglion, which lies over the root of the renal artery, 

 and terminating in this ganglion will be found the small splanchnic nerve, 

 after it has pierced the crus of the diaphragm. The least splanchnic nerve, 

 if present, may pierce the crus, or it may pass behind the Ugamentum 



