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THE ABDOMINAL VISCEEA. 1425 



le lower than the left, as well as a little further away from the median plane. 

 The hilum of the right kidney lies 2 in. from the median plane ; that of the left 

 1| in. from the median plane. For practical purposes the hilum of the kidney may 

 be regarded as opposite a point on the anterior abdominal wall a finger's breadth 

 medial to the tip of the ninth costal cartilage ; and a line joining the two hila 

 crosses the vertebral column opposite the fibro-cartilage between the first and second 

 lumbar vertebrae, that is to say, a little below the transpyloric line. The highest 

 point of the kidney is situated two inches from the median plane, on a level with a 

 line crossing the abdomen midway between the xiphisternal and transpyloric 

 planes. The lowest point of the kidney reaches down to, or a little below, the 

 infra-costal plane. 



The student should make himself familiar with the feel of the parts in relation 

 to the kidneys, as far as they can be made out by introducing the hand through a 

 median abdominal incision. 



The superior half of the anterior surface of the right kidney is felt, at the bottom 

 of the hepato-renal peritoneal pouch, by passing the hand deeply into the right 

 hypochondrium, between the anterior margin of the liver and the right flexure of the 

 colon. The inferior half is palpated by passing the hand deeply into the highest 

 part of the right infra-colic peritoneal compartment ; its free peritoneal suri'ace lies 

 in the angle of the right flexure of the colon. The second portion of the duodenum 

 overlaps both the supra- and infra-colic portions of the medial border of the right 

 kidney. When the right kidney is excised by the abdominal route, the peritoneum 

 is divided lateral to the ascending colon and right colic flexure, and these structures, 

 along with the descending part of the duodenum, are stripped off the organ in a 

 medial direction, until the hilum and the renal vessels are reached. 



The left kidney is crossed transversely, about its middle, by the body of the 

 pancreas and the splenic vessels. To palpate the supra-pancreatic portion, the 

 hand is passed through the left portion of the gastro-colic ligament, upwards 

 behind the stomach, into the superior part of the omental bursa. The spleen will 

 be felt to overlap the lateral border of the kidney. To palpate the infra-pancreatic 

 portion of the organ, which is covered by the peritoneum continued downwards 

 from the attachment of the inferior layer of the transverse mesocolon, the hand is 

 passed deeply into the upper part of the left infra-colic peritoneal compartment as 

 far as the angle of the left flexure of the colon. This area of the kidney is over- 

 lapped by coils of small intestine, while passing transversely laterally in front of 

 it are the left colic artery and its branches. When the left kidney is excised by 

 the transperitoneal route, the left colic flexure and the descending colon are 

 mobilised by dividing the peritoneum lateral to them so as not to injure the left 

 colic artery. 



In addition to their true fibrous capsules, the kidneys are surrounded by and 

 enveloped in a well-marked fatty capsule. Outside this perinephric fat is a more or 

 less well-defined fibrous envelope, known as the renal fascia or fascia of Gerota, 

 which forms, as it were, a sheath to the organ. Hence, just as in the case of the 

 prostate and thyreoid glands, the kidney possesses, in addition to its true capsule, 

 a sheath derived from the neighbouring fasciae. The anterior and posterior layers 

 of the sheath remain distinct at the medial border of the kidney and are prolonged, 

 the one in front of, and the other behind the renal vessels. The two layers 

 remain separate also for some distance below the inferior pole of the kidney, and it 

 is into this downward extension of the fascial compartment that the kidney descends 

 in the condition known as movable kidney. Above and laterally the sheath joins 

 the fascial lining of the diaphragm and transversus muscles respectively. Outside 

 the perinephric fascia is a second layer of fat sometimes spoken of as the 

 paranephric fat. 



When the inferior pole of the kidney receives a special blood supply, either 

 directly from the aorta, or from the renal artery, the abnormal vessel may, by 

 passing either in front or behind the superior part of the ureter, cause the latter to 

 be so kinked over the vessel as to cause a secondary hydronephrosis. 



Brodel has shown that the branches of the renal artery are distributed to the 

 cortex of the kidney in an anterior and a posterior group ; hence, in splitting the 



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