1422 SUEFACE AND SUKGICAL ANATOMY. 



is simply to pull the caecum out of the wound, and if the parts are normal the 

 process will be delivered along with it ; if, on the other hand, the csecum and 

 vermiform process are tacked down by adhesions, the vermiform process is best 

 discovered by following the anterior tsenia coli to the root of the process. 



Ascending Colon. The ascending colon, after crossing the iliac crest, lies deeply 

 in the right lumbar region upon the fascia covering the quadratus lumborum and 

 the adjacent aponeurotic origin of the transversus abdominis. Between the bowel 

 and the fascia is a quantity of loose cellular- tissue and fat, which may be< the seat 

 of a large abscess, secondary, (1) more especially, to disease of the colon itself, (2) 

 to disease of a retro-colic vermiform process, or (3) to disease of the right kidney. 

 This cellular tissue is directly continuous above with a thin layer lining the inferior 

 surface of the diaphragm; hence the suppurative process may extend upwards, 

 giving rise to one form of subphrenic abscess. In some cases the ascending colon is 

 completely surrounded by peritoneum, and it may even be provided with a distinct 

 mesentery. The latter condition is almost invariably present in infants sufferiug 

 from extensive ileo-csecal intussusception. After the invagination has been 

 reduced the mesentery proper is seen to be continuous, through the ascending 

 mesocolon, with the mesentery of the transverse colon. 



In order to resect the ascending colon the surgeon mobilises it by dividing the 

 peritoneum along its line of reflection from the lateral aspect of the colon on to 

 the abdominal wall. The colon, along with the posterior peritoneum medial to it, 

 is then stripped, from the lateral side towards the median plane, off the quadratus 

 lumborum, the psoas, and the inferior pole of the right kidney. While this is being 

 done, the branches of the ileo-colic and right colic vessels which pass laterally to 

 supply the gut are secured, and the lymph vessels and associated lymph glands are 

 removed along with the bowel. As the peritoneum is stripped off, care must be taken 

 not to injure the important structures which lie behind it, namely, the duodenum, 

 the ureter, and the spermatic vessels. 



The right colic flexure reaches upwards beneath the tenth costal cartilage 

 into the most inferior part of the right hypochondrium, where it lies immediately 

 to the right of the gall-bladder, between the liver and the inferior half of the 

 anterior surface of the kidney. Posteriorly, it is separated from the anterior surface 

 of the right kidney by a quantity of loose cellular tissue ; hence by dividing the 

 peritoneum to the right side of the flexure it can readily be mobilised and separated 

 from the kidney. 



Transverse Colon. The transverse colon crosses the lower part of the umbilical 

 region immediately below the greater curvature of the stomach. In cases of chronic 

 constipation it may form a U-shaped or V-shaped loop, extending down to the level] 

 of the pubes. When this is the case the natural kinking at the right and left colic | 

 flexures becomes more acute, and tends, therefore, to aggravate the constipation. Ii 

 such cases the right and left portions of the transverse colon often lie parallel an< 

 close to the ascending and descending colon, respectively, like the barrels of a gun. 



The transverse colon receives its blood-supply from the arch formed by the 

 middle and left colic arteries. The arch lies in the posterior wall of the bursa 

 ornentalis between the two layers of the transverse mesocolon. In resecting portiom 

 of the stomach for malignant disease, the surgeon removes also the glands whict 

 lie between the two layers of the gastro-colic ligament in relation to the right 

 gastro-epiploic vessels. At this step of the operation care must be taken not to en- 

 danger the blood-supply of the transverse colon by injuring the middle colic artery 



The left colic flexure is more acute and more fixed than the right flexure ; anc 

 it is situated at a higher level as well as more deeply. A tumour originating ii 

 this portion of intestine lies generally under cover of the left costal margin, and i 

 therefore difficult to palpate. To expose the left colic flexure, the omentum alond 

 with the transverse colon and the body of the stomach is turned upwards. T 

 mobilise it for the purpose of resection the surgeon must divide : (1) the phrenicoj 

 colic ligament, which attaches it to the diaphragm opposite the eleventh rib; (2J 

 the left border of the greater omentum, which attaches it to the stomach ; an 

 (3) the left portion of the transverse mesocolon, which attaches it to the 

 extremity of the pancreas. 



