THE ABDOMINAL CAVITY 339 



After the abdomen has been opened (p. 250), the surgeon 

 (i) may first ligature the ileo-colic and right colic arteries and 

 then proceed to free the bowel ; or (2) he may free the bowel 

 first and secure the vessels at a later stage. In the first method 

 the vessels are found behind the peritoneum on the posterior 

 wall of the right infra-colic compartment (Fig. 107). 



In the second method a vertical incision is made through 

 the peritoneum of the floor of the right para-colic gutter in its 

 whole extent, and it is then continued to the left behind the 

 caecum and below the ileum. The csecum and ascending colon 

 are then freed by dissecting with the fingers, and the peritoneum 

 is stripped off the posterior wall of the right infra-colic com- 

 partment. During these stages of the operation care must 

 be taken not to injure the right spermatic vessels, ureter, or the 

 second part of the duodenum (Fig. 107). The contents of the 

 right iliac fossa can now be drawn out of the abdomen and 

 turned over towards the left. While this is being done, the 

 right colic and ileo-colic vessels are secured on the deep surface 

 of the peritoneum. The ileum and ascending (or transverse) 

 colon are then clamped and divided, and the intervening portion 

 of bowel is removed, together with the adjoining area of 

 peritoneum up to the point where the arteries have been 

 ligatured. As the ileo-colic artery has been tied, the terminal 

 six inches of the ileum is dependent for its blood-supply on 

 the anastomosis between the ileo-colic and the termination of 

 the superior mesenteric. It is thus rendered unsuitable for 

 intestinal anastomosis and must be resected in order that the 

 piece of the ileum which is utilised for this purpose may possess 

 a free and ample blood-supply. 



The Left Colic (Splenic) Flexure is deeply situated 

 under cover of the costal margin and is partially overlapped 

 by the stomach. On this account its examination is by no 

 means easy, and, therefore, tumours of the flexure are not 

 readily recognised at an early stage. Radiograms demonstrate 

 that its position is very constant. It lies under cover of the 

 eighth rib and its costal cartilage, to the left side of the left 

 lateral line, and it is held in place by its peritoneal connections. 

 Its upper aspect receives the attachment of the upper end of 

 the left border of the greater omentum ; its posterior surface 

 is attached to the pancreas by the left extremity of the transverse 

 mesocolon ; and, from its lateral aspect, the peritoneum passes 

 to the diaphragm forming a fold, which is called the phrenico- 



22 a 



