314 THE ABDOMEN- AND PELVIS 



ducts occurs quite close to the neck of the gall-bladder. The 

 lining mucous membrane is redundant and projects into the 

 lumen as a spiral fold, the valve of Heister, which obstructs the 

 passage of a probe except when the duct is greatly enlarged 

 owing to the passage of stones or to intermittent obstruction 

 of the common duct. 



The cystic duct may be examined by tracing the gall-bladder 

 upwards, backwards, and medially to the porta hepatis, where 

 it is associated with one or two lymph glands. 



The Common Hepatic Duct is a short trunk formed by 

 the union of the right and left hepatic ducts in the porta (hilum) 

 of the liver. 



The Bile-Duct is formed immediately below the porta of 

 the liver by the union of the cystic with the common hepatic 

 duct. It is three to four inches long and passes downwards (i) 

 in the lesser omentum, (2) behind the first part of the duodenum, 

 and (3) postero-lateral to the head of the pancreas, to terminate 

 by opening into the second part of the duodenum. 



The first or supra -duodenal portion of the bile-duct 

 is about ij inches long. It descends in the right border of the 

 lesser omentum, lying in front of the portal vein and to the right 

 side of the hepatic artery. Several lymph glands are closely 

 related to the bile-duct at its commencement and near its 

 termination, and they are apt to become enlarged in septic 

 conditions of the gall-bladder and bile-duct, and in malignant 

 disease of the lesser curvature of the stomach and of the pancreas. 

 When enlarged they may be mistaken for impacted gall-stones. 



The surgical approach to the gall-bladder (p. 252) is planned 

 so as to afford sufficient exposure for a thorough examination 

 of the bile-passages as well. After the gall-bladder has been 

 dealt with, the index finger of the left hand is passed along its 

 inferior surface and introduced into the epiploic foramen (of 

 Winslow). If the hepato-colic ligament (p. 279) is present, it 

 must be divided to improve the access. The supra-duodenal 

 portion of the bile-duct may then be palpated between the left 

 forefinger and thumb, and if a stone is detected it should be 

 " milked " back along the cystic duct into the gall-bladder. 

 When the stone is impacted, the duct is hooked forwards to 

 the surface and incised longitudinally to permit of its extraction. 

 Advantage may be taken of this opening to pass a probe upwards 

 to explore the hepatic ducts, and downwards to the ampulla 

 of Vater. 



