CHAP. III.] 



PANCREATIC FISTULA. 



193 



Heidenhain's 

 method of es- 

 tablishing a 

 temporary 

 fistula. 



^he ^og to be subjected to operation must be kept 

 without food for 3$, hours before the operation, and be 

 deeply narcotized with morphia. An incision is then made 

 in the linea alba, midway between the xyphoid process 

 an( j th e umbilicus. The descending part of the duodenum 

 is then drawn out so as to bring into view the adjacent part of the 

 pancreas. In order to find the duct, the following distinguishing character 

 serves : At the part where the lower lobe of the pancreas recedes from 

 the concave side of the duodenum, there is seen a transparent bridge of 

 mesentery intervening between the intestine and the gland. In this is 

 situated a thick intestinal vein. 



On the upper side of this vein the pancreas is directly applied to the 

 intestine ; between the vein and the attached part of the pancreas are 

 situated some coarse bundles of vessels. Now, usually, the pancreatic duct 

 runs between the bundles of vessels and the vein; less frequently it is 

 situated between the second and third of the above-mentioned bundles 

 of vessels, whilst in unfavourable cases the bundle is covered by vessels. 

 The length of the duct is here only a few millimetres. By the aid of 

 carbolized ligatures a short glass cannula, having a length of from 6 18 

 millimetres, is tied in ; the cannula has attached to it some thick-walled 

 india-rubber tube. The intestine is provisionally attached to the abdominal 

 wall by two loose ligatures, one being situated above and a second below 

 the duct, the object being to secure adhesion between the intestinal and the 

 abdominal wall. The wound in the abdominal wall is closed, room being 



JB' 



FIG. 13. CANNULA INSERTED INTO THE PANCREATIC DUCT AND ATTACHED TO THE 

 INTESTINAL WALL. (Bernard, see p. 192.) 



merely left for the cannula. The ligatures connected with the intestine 

 are removed after 24 hours, the sutures through the abdominal wall 

 after 36 48 hours. Almost invariably the cannula falls out in a few 

 days. 



G. 



13 



