THE ABDOMINAL CAVITY 309 



eighth and ninth costal cartilages may be resected, but the 

 seventh must be left in situ on account of the danger of opening 

 into the right pleural sac (Fig. 97). 



The Right Lateral Surface of the liver lies under cover of 

 the seventh, eighth, ninth, tenth, and eleventh ribs, and extends 

 a little below the costal margin in the mid-axillary line. It 

 lies in contact with the diaphragm, and is overlapped by the 

 right pleura in rather more than its upper two-thirds (Fig. 151). 

 It is entirely covered by peritoneum, and a recess of the 

 greater sac extends upwards between it and the diaphragm. 



Solitary abscess of the liver is commonly situated near 

 the upper surface of the right lobe, and as it enlarges it displaces 

 the diaphragm in an upward direction. Evacuation of a liver 

 abscess is carried out from the right side by means of a curved 

 incision, convex downwards, which is planned so as to expose the 

 eighth and ninth ribs and the adjoining intercostal spaces. The 

 flap, which consists of skin and fasciae, is turned upwards, and 

 a portion of one or both of the ribs exposed is resected sub- 

 periosteafly. The periosteum and the costal pleura on its 

 deep surface are then incised. Usually the pleural sac in this 

 situation is found obliterated by adhesions, but if not, the cavity 

 must be shut off by suturing the upper cut margin of the costal 

 pleura to the diaphragmatic pleura. It will probably be 

 necessary to ligature the intercostal vessels of the space below 

 the rib excised. An incision is then made through the diaphragm 

 into the liver, to which it is generally firmly adherent. The 

 adhesions, which are due to perihepatitis, entirely obliterate 

 the peritoneal recess, which separates the liver from the 

 diaphragm. Sinus forceps can now be thrust through the liver 

 substance into the abscess cavity. A drainage tube may be 

 inserted and brought to the surface through a stab wound in 

 the flap, so that the original incision can be closed. 



The Superior Surface of the liver is in contact with the dia- 

 phragm, and both are covered by peritoneum. It is related above 

 to both lungs and pleural sacs, and to the heart and pericardium. 



When a liver abscess ruptures spontaneously it usually does 

 so through the superior surface, after it has become adherent 

 to the diaphragm. It thus enters the pleural sac and gives rise 

 to an empyaema. It sometimes happens that adhesions have 

 fixed the basal surface of the lung to the diaphragmatic pleura, 

 and in these cases the pus ruptures into the lung, being sub- 

 sequently evacuated by coughing. 



206 



