1418 SUKFACE AND SUKGICAL ANATOMY. 



tubular form, and the axis of its body becomes more oblique. In the infant and 

 young child the stomach is flask-shaped rather than J -shaped, and its axis is less 

 vertical than in the adult. The elongated form of the adult stomach is acquired 

 as a result of the erect posture. 



It must be remembered that the only really fixed part of the stomach is the 

 region of the cardia, so that the form and position of the organ may be considerably 

 influenced by the condition of the neighbouring organs. For example, it may be 

 displaced downwards and to the left by enlargement of the liver, upwards by 

 distension of the intestines, and to the right by distension of the left colic flexure. 



Overlying the stomach is an important surface area known to clinicians as the 

 semilunar space of Traube. This space, which yields a deeply tympanitic note on 

 percussion, is bounded, above, by the inferior margin of the left lung ; below, by the 

 left costal margin ; t to the right, by the anterior margin of the left lobe of the liver ; 

 behind and to the left, by the anterior border and anterior basal angle of the spleen. 

 The line of the costo-diaphragmatic pleural reflection crosses the space about mid- 

 way between its superior and inferior limits. The tympanitic area of the space is 

 diminished superiorly by pleuritic effusion, towards the right by enlargement of 

 the liver, and towards the left by enlargement of the spleen. 



Perforation of an ulcer on the anterior wall of the stomach leads to extravasa- 

 tion into the greater sac of the peritoneum, while if the perforated ulcer is on the 

 posterior wall, extravasation takes place into the omental bursa. The close relation 

 of the splenic artery and its branches to the posterior wall of the stomach explains 

 the severe haemorrhage which is sometimes caused by a posterior gastric ulcer. 

 The surgeon may reach the posterior wall of the stomach through the gastro-colic 

 ligament, or, after throwing upwards the greater omentum and transverse colon, by 

 traversing the transverse mesocolon ; by the former route the posterior wall of the 

 stomach is reached through the anterior wall of the omental bursa, in the latter 

 through its posterior wall. 



When a partial resection of the stomach, for malignant disease, is performed, the 

 bleeding is controlled by ligaturing the main vessels at an early stage of the opera- 

 tion. These are the right and left gastrics at the lesser curvature, the gastro- 

 duodenal behind the first part of the duodenum, and the right and left gastro- 

 epiploics at the greater curvature. The left gastric should be ligatured as near 

 the cardia as possible, so that the whole chain of lymph glands along the lesser 

 curvature may be removed. Care is taken to remove also all the glands which lie 

 behind the first part of the duodenum in relation to the gastro-duodenal artery and 

 head of the pancreas, as well as those along the right half of the greater curvature 

 in relation to the right gastro-epiploic artery. If the disease has spread to the 

 retro-peritoneal lymph glands, surrounding the cceliac artery, above the pancreas, 

 the chances of a permanent recovery are very remote. 



In the classical " no-loop " gastro-enterostomy operation a longitudinal opening 

 in the commencement of the jejunum is anastomosed by suturing it to an opening 

 in the posterior wall of the stomach, near the 'greater curvature. The jejunum is 

 applied to the stomach in such a way that it maintains its normal direction, namely, 

 obliquely upwards and to the left. To bring the surfaces of the two organs in 

 contact, surgeons are in the habit of protruding the posterior wall of the stomach 

 through an opening made in the transverse mesocolon, on the proximal side of the 

 arch formed by the middle and left colic arteries. A better plan, however, is to 

 make an opening also into the omental bursa through the gastro-colic ligament a 

 little below the gastro-epiploic vessels, and then to bring the jejunum into contact 

 with the posterior wall of the stomach by pushing it (the jejunum) upwards 

 through the opening in the transverse mesocolon. By this plan the posterior wall 

 of the stomach along with the jejunum can be protruded through an opening in 

 the gastro-colic ligament, and can be more easily delivered out of the abdominal 

 cavity. 



When the posterior wall of the stomach and transverse colon are held down by 

 adhesions, a long loop of jejunum is brought up in front of the greater omentum 

 and transverse colon and anastomosed to the anterior wall of the stomach. 



The Duodenum. The duodenum is the widest, thickest, and most fixed part 



