THE ABDOMINAL CAVITY 315 



The second or retro -duodenal part of the bile-duct 



descends behind the first part of the duodenum, to the right of 

 the portal vein and in front of the inferior vena cava (Fig. 87). 

 Its length, usually about one inch, depends upon the upward 

 extent of the head of the pancreas. In order to examine this 

 part of the bile-duct the finger is again introduced into the 

 epiploic foramen and the thumb is placed on the antero-lateral 

 aspect of the first part of the duodenum. When the two are 

 squeezed together the presence of one or more impacted stones 

 can be recognised. It may be necessary to expose the second 

 part of the bile-duct (p. 306), but the stone can sometimes be 

 manipulated downwards into the duodenum, or upwards into 

 the first part of the bile-duct, or it may even be made to retrace 

 its course along the cystic duct into the gall-bladder. 



The third or pancreatic portion of the bile-duct passes 

 downwards and slightly to the right and terminates by piercing 

 the postero-medial aspect of the second part of the duodenum 

 about its middle. It is about i J inches long and lies in a groove 

 on the postero-lateral aspect of the head of the pancreas, being 

 sometimes embedded in its substance. It is separated from 

 the anterior surface of the inferior vena cava by some fibrous 

 tissue. The superior pancreatico-duodenal artery lies first to 

 the right side of the bile-duct and then crosses in front of its 

 lower end. Very often, however, the artery passes behind the 

 duct, and in these cases may give rise to haemorrhage when 

 the pancreatic portion is being exposed. In this operation 

 haemorrhage may also be caused by injury of a vein, which issues 

 from the posterior aspect of the head of the pancreas and runs 

 upwards and medially, along the medial side of the pancreatic 

 part of the bile-duct, to join the portal vein. As the bile-duct 

 enters the wall of the duodenum it is joined, on its left side, by 

 the pancreatic duct, and the two open into a dilatation of the 

 canal the ampulla of Vater which lies partly within the wall 

 (Fig. 98). The opening from the ampulla into the duodenum is 

 placed on the duodenal (bile) papilla, and is so small that gall- 

 stones, which have passed along the whole length of the cystic 

 and bile ducts, often become impacted in the ampulla. When 

 this occurs, the pancreatic secretion as well as the bile may be 

 prevented from entering the duodenum, unless a communication 

 exists between the main pancreatic and the accessory duct 

 (p. 319). In addition, septic infection, which commonly exists 

 in the presence of gall-stones, is apt to spread along the pancreatic 



