344 THE ABDOMEN AND PELVIS 



is short it may be necessary to mobilise the lowest portion of 

 the iliac colon. This can be effected by dividing the peritoneum 

 along the left paracolic gutter and stripping the bowel medially 

 on a hinge of peritoneum. The lateral cutaneous nerve of the 

 thigh ; the ductus deferens, the internal spermatic vessels, and 

 the genito-femoral nerve may be injured unless care is exercised 

 at this stage of the operation. In addition, the ureter, which is 

 crossed by the root of the pelvic meso-colon near the apex of 

 the V, and the inferior mesenteric artery and its terminal branch 

 which runs downwards in the descending limb of the pelvic 

 meso-colon (Fig. 107), must all be preserved. 



Transplantation of Ureters. The mobility of the pelvic 

 colon renders it suitable for the implantation of the divided 

 ureters in cases of extroversion of the bladder and in epi- 

 spadias (in both sexes) with associated incontinence of urine 

 (Stiles). It might be supposed that the introduction of the 

 ureters into a septic tube would lead to an ascending infection 

 of the urinary tract, but provided that the urine, ureters, and 

 kidneys are healthy there is no risk of such an occurrence. 

 After the operation the bowels may be unnaturally loose for 

 a time, but the rectum rapidly becomes tolerant of the presence 

 of the urine so that the bowels act only once or twice a day. 



The operation of transplantation is performed in two stages, 

 an interval of a fortnight being allowed to elapse before the 

 second ureter is transplanted. 



Very careful preparation of the patient on each occasion is 

 essential to ensure an empty pelvic colon. 



The patient is placed in an exaggerated Trendelenburg 

 position in order to facilitate the exposure of the ureters. A 

 vertical incision through the left rectus gives good access, due 

 care being taken to ligate the inferior epigastric artery. In 

 the case of the left ureter, the coils of small intestine are displaced 

 upwards, and the pelvic colon is identified. It is then turned 

 upwards, and the peritoneum in the floor of the intersigmoid 

 fossa (Fig. 107) is carefully divided. The pelvic portion of 

 the ureter is now exposed and may be traced downwards and 

 freed before it is ligated and divided. Its extremity is then 

 implanted into the ascending limb of the gut, and the adjacent 

 part of it is buried in the wall of the bowel after the manner 

 adopted in Witzel's gastrostomy. The peritoneal and abdominal 

 incisions are then closed. 



The right ureter is found near the medial border of the right 



