1358 THE URINOGENITAL ORGANS 



The kidney may be exposed either by a lumbar or abdominal incision. The operation is 

 best performed by a lumbar incision, except in a case of very large tumor or of wandering kid- 

 ney with a loose mesonephron, on account of the advantages which it possesses of not opening 

 the peritoneum and of affording admirable drainage. It may be performed either by an oblique, 

 a vertical, or a transverse incision. A common incision for exposing the kidney begins an inch 

 below the twelfth rib, at the margin of the Erector spinae muscle, and passes obliquely down- 

 ward and forward, exposing the anterior border of the Latissimus dorsi and the posterior border 

 of the Internal oblique. The surgeon divides the posterior leaflet of the lumbar fascia, draws 

 aside or incises the Quadratus lumborum, and cuts the anterior leaflet of the lumbar fascia and 

 also the transversalis fascia. He opens the fatty capsule down to the kidney and strips it from 

 the true capsule, bringing the kidney outside of the body for inspection. The vertical incision 

 at the edge of the Erector spinae muscle is frequently used. A gridiron or muscle-splitting 

 operation is used by some in order to avoid the division of nerves, vessels, and muscle fibres. 



The abdominal operation is best performed by an incision in the linea semilunaris on the 

 side of the kidney to be removed, as recommended by Langenbuch; the kidney is then reached 

 from the outer side of the colon, ascending or descending, as the case may be, and the vessels 

 of the colon are not interfered with. If the incision were made in the linea alba, the kidney 

 would be reached from the inner side of the colon, and the vessels running to supply the colon 

 would necessarily be interfered with. The incision is made of varying length according to the 

 size of the kidney, and comjnences just below the costal arch. The abdominal cavity is opened. 

 The intestines are held aside, and the outer layer of the mesocolon incised, so that the fingers 

 can be introduced behind the peritoneum and the renal vessels are sought for. These vessels 

 are then to be ligated; if tied separately, care must be taken to ligate the artery first. The 

 kidney must now be enucleated, and the vessels and the ureter divided, and the latter disinfected 

 and tied, and, if it is thought necessary, stitched to the edge of the wound. 



THE URETERS (Figs. 1087, 1096). 



The ureters are the two tubes which convey the urine from the kidneys into the 

 bladder. Each ureter commences within the sinus of the corresponding kidney 

 by a number of short cup-shaped branches, the minor calices or infundibula, 

 which unite either directly or indirectly to form a dilated pouch, the pelvis (Fig. 

 1096), from which the ureter, after passing through the hilum of the kidney, 

 descends to the bladder. The minor calices encircle the apices of the renal papillae; 

 but inasmuch as one calk may include two or even more papillae, their number 

 is generally less than the pyramids themselves. The minor calices vary in number 

 from ten to twenty or more. These calices converge into two or three tubular 

 divisions, the major calices, which by their junction form the pelvis or dilated 

 portion of the ureter, which is situated behind the renal vessels and which lies 

 partly within and partly outside the renal sinus. It is usually placed on a level 

 with the spinous process of the first lumbar vertebra. 



The ureter proper is a cylindrical membranous tube, about ten to twelve inches 

 (25 to 30 cm.) in length and about one-sixth inch (4 mm.) in diameter, directly 

 continuous near the lower end of the kidney with the tapering extremity of the 

 pelvis. Its walls are from 1 to 2 mm. thick, and its calibre varies. It exhibits 

 four main constrictions (1) at its junction with its pelvis; (2) as it passes over the 

 brim of the pelvis; (3) as it enters the bladder; (4) at its termination. Its course 

 is obliquely downward and inward through the lumbar region (pars abdominalis) 

 (Fig. 1087), into the cavity of the pelvis (pars pelvina) (Fig. 1107), where it passes 

 downward, forward, and inward across that cavity to the base of the bladder, 

 into which it then opens by a consJa^cte^Lorifice (orificium ureteris) (Fig. 1117), 

 after having passed obliquely for nearTyan inch between the vesical muscular 

 and mucous coats (Fig. 1106). The lower part of the abdominal portion of the 

 ureter exhibits a spindle-shaped dilatation. 



Relations (Fig. 1107). The abdominal part lies behind the peritoneum on the inner part of 

 Fsoas muscle, and is crossed obliquely by the spermatic or ovarian vessels. It enters the 

 pelvic cavity by crossing either the termination of the common, or the commencement of the 

 external, iliac vessels. 



