THE ABDOMINAL CAVITY 321 



(p. 292). In puncture of the normal spleen, the needle must 

 pass through the muscular wall, the pleural sac, the diaphragm 

 and the peritoneal cavity before the organ is reached. 



The splenic artery has already been described (p. 296). 



The splenic vein issues from the hilUm of the spleen and 

 is at once joined by the left gastro-epiploic veins and the venae 

 breves, which pass from the stomach between the two layers 

 of the gastro-splenic ligament. It then runs backwards in the 

 lieno-renal ligament to the posterior abdominal wall, where it 

 turns to the right behind the pancreas. It receives numerous 

 pancreatic veins, and is joined, near its termination, by the 

 inferior mesenteric vein. Behind the neck of the pancreas it 

 is joined by the superior mesenteric vein, and the two together 

 form the portal vein. Portal obstruction, therefore, invariably 

 gives rise to venous congestion of the spleen (p. 310). 



The lymph vessels of the spleen terminate in the lymph 

 glands at the hilum. From these splenic glands the afferents 

 pass to the pancreatic and cceliac lymph glands. 



Splenic Enlargement. When the spleen becomes enlarged, 

 in malaria, splenic anaemia and other diseases, its anterior 

 border projects beyond the left costal margin and is in contact 

 with the deep surface of the anterior abdominal wall. Normally 

 this border possesses one or two notches or indentations, and in 

 splenic enlargement the notches become more pronounced. On 

 palpation of a tumour in the left lumbar region, the discovery of one 

 or more notches on its anterior border may settle the diagnosis. 



The direction taken by the enlarging spleen is usually 

 obliquely downwards and medially, as the phrenico-colic ligament 

 and the splenic flexure obstruct its enlargement in a purely 

 downward direction. 



Splenectomy. Owing to its vascularity, stab wounds or rupture of the 

 spleen give rise to severe haemorrhage, and removal of the organ may be 

 necessary. Good access is obtained by an incision similar to that described 

 for operations on the gall-bladder (p. 25 2), but on the opposite side, or by a 

 long vertical incision through the left rectus. Thereafter, two methods 

 are open to the surgeon, (i) The omental bursa is opened by tearing 

 through the greater omentum just above the transverse colon. The stomach 

 is retracted upwards and the peritoneum is cautiously divided at the upper 

 border of the pancreas. The splenic artery is exposed and the vein is found 

 at a slightly lower level. Both vessels are tied in this situation, and the 

 haemorrhage is at once reduced. The gastro-splenic ligament may now be 

 ligatured and divided piece by piece. When the lieno-renal ligament has been 

 similarly treated, the spleen can be removed. 



(2) The spleen is drawn forwards to the abdominal wound, and the left 

 side of the lieno-renal ligament is exposed. The ligament is ligatured and 

 divided piece by piece. The spleen is then drawn over to the left in order 



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