1416 SURFACE AND SURGICAL ANATOMY. 



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 

 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- 

 duodenal artery behind the superior part of the duodenum about a finger's breadth 

 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 portse. 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 epi- 

 gastric 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 to 

 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 and 

 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 lies 

 at the level of the fifth rib in the mammary line, a little above and behind the 



