296 THE ABDOMEN AND PELVIS 



In searching for the site of a perforated ulcer, the whole of 

 the antero-superior surface of the stomach and the anterior 

 surface of the first part of the duodenum must be examined. 



If gastric contents are not found in the supra-colic com- 

 partment when the abdomen is opened, the postero-inferior 

 surface of the stomach must be exposed and examined. Before 

 doing so, the surgeon explores the epiploic foramen (of Winslow), 

 and if it is found closed by adhesions, the diagnosis of a perforated 

 ulcer leaking into the omental bursa may be made with some 

 confidence. In order to gain access to the postero-inferior 

 surface of the stomach, it is necessary to open into the omental 

 bursa. This can be done by carefully tearing through the 

 greater omentum about three inches to the left of the pylorus 

 and immediately below the gastro-epiploic vessels (p. 297). 

 The greater curvature is then turned forwards and upwards, 

 and, as a result, a large part of the postero-inferior surface of 

 the stomach can be both seen and felt through the opening in 

 the omentum. The cardia and the upper part of this surface 

 may be examined by tearing through the thinnest part of the 

 lesser omentum and everting the posterior surface of the stomach 

 through the opening thus made. 



The Arterial Supply of the stomach is derived, either 

 directly or indirectly, from the cceliac (axis) artery, which arises 

 from the aorta just above the neck of the pancreas and at once 

 divides into (i) the left gastric, (2) the splenic, and (3) the 

 hepatic arteries. 



1. The left gastric (coronary) artery passes upwards behind the 

 omental bursa to the cesophageal opening in the diaphragm. There it comes 

 into contact with the cardia, and having given off one or two ascending 

 branches to the oesophagus, it descends along the lesser curvature from left 

 to right. It usually divides into two parallel branches, which anastomose 

 with the right gastric (pyloric) artery. 



2. The hepatic artery runs to the right along the upper border of the 

 pancreas, turns forwards round the right border of the omental bursa just 

 below the epiploic foramen, and reaches the first part of the duodenum. It 

 then turns upwards and ascends between the two layers of the lesser omentum 

 to the liver, in close relation to the bile-duct and portal vein (p. 314). 



As the hepatic artery passes round the right border of the omental bursa, 

 it gives off the right gastric, which runs to the left along the lesser curvature 

 and anastomoses with the left gastric. 



The gastro-duodenal artery arises from the hepatic at the upper border 

 of the first part of the duodenum. It descends behind the duodenum to its 

 lower border and there divides into the superior pancreatico-duodenal (p. 324) 

 and the right gastro-epiploic arteries. The latter passes to the left along the 

 greater curvature of the stomach and anastomoses with the left gastro- 

 epiploic. 



3. The splenic artery runs to the left behind the omental bursa. It 



