312 THE ABDOMEN AND PELVIS 



bladder is directed upwards, backwards, and medially towards 

 the porta (hilum) of the liver, where it becomes narrowed to 

 form the cystic duct. On its medial side and inferiorly lie 

 the first part and the commencement of the second part of the 

 duodenum ; below and to its lateral side it is in relation to 

 the right colic flexure and the commencement of the transverse 

 colon. After prolonged cholecystitis, it may be united to these 

 viscera by dense adhesions, and occasionally gall-stones may 

 ulcerate through its wall and be discharged into the intestinal 

 canal. 



The cystic artery arises from the right terminal branch of the 

 hepatic and runs to the right, crossing in front of the common 

 hepatic duct. It divides into a superficial branch which 

 supplies the inferior surface of the gall-bladder, and a deep 

 branch which ramifies between its upper surface and the liver. 

 The cystic vein joins the vena portse. 



Cholecystectomy. Ligation of the cystic artery and duct 

 constitutes the first step in cholecystectomy. This is carried 

 out close to the origin of the vessel in order to prevent the 

 haemorrhage which would otherwise occur when the gall-bladder 

 is stripped from its bed. The peritoneum is then incised along 

 the inferior surface of the gall-bladder and separated from it. 

 After the viscus has been freed from the liver and excised, the 

 cut edges of the peritoneum are united over the exposed area 

 of liver substance. 



Pancreatitis may accompany or follow cholecystitis, and 

 produce jaundice by pressure on the bile-duct. On this account 

 the gall-bladder is retained if at all possible, for cholecyst- 

 enterostomy may subsequently be necessary in order to relieve 

 the condition. 



The Nerve-Supply of the Gall-Bladder is derived from 

 (1} the right phrenic (C. 3, 4, and 5), (2) the vagus, and (j) the 

 cceliac sympathetic plexus (Th. 7-9). The repeated attempts 

 of the gall-bladder to expel calculi into the cystic duct give rise 

 to referred pain, which is commonly felt in the right half of the 

 epigastrium, but severe pain is sometimes experienced over 

 the right shoulder or in the posterior cervical region. In both 

 the latter cases the afferent stimulus does not pass via the 

 sympathetic but by the phrenic nerve. The viscero-motor 

 reflex is frequently present in the upper part of the right rectus. 

 These attacks of biliary colic cease when the stone has accom- 

 plished its journey along the bile-duct into the duodenum, or 



