THE ABDOMINAL CAVITY 349 



which the question arises as to whether a certain shadow may 

 or may not be produced by a calculus. 



The shadows thrown by phleboliths or calcareous deposits 

 in the mesenteric or iliac lymph glands may be difficult to 

 distinguish from shadows caused by ureteral calculi (Figs. 108 

 and 109). Phleboliths, however, are much more commonly 

 found in the vesico-prostatic veins (p. 365), but even in this 

 position they may throw shadows in relation to the vesical 

 openings of the ureters. 



Although the normal line of the ureter passes through the 

 tips of the lumbar transverse processes, shadows found more 

 medially may nevertheless be due to ureteral calculi, because 

 when hypertrophied as the result of urinary obstruction, the 

 ureter takes an irregular downward course. 



The peri-nephric fascia and the posterior relations of the 

 kidneys have already been described (p. 271). 



The Right Kidney is in contact, anteriorly, with the 

 suprarenal gland, the liver, the right colic flexure, and the 

 duodenum. The suprarenal gland lies on its upper pole, and 

 below that, the liver covers nearly two-thirds of its anterior 

 surface. The second part of the duodenum lies along the medial 

 border overlapping the hilum, and the right colic flexure covers 

 the infero-lateral part of this surface. Over the hepatic area 

 the peritoneum is in direct contact with the kidney, forming 

 the posterior wall of the hepato-renal recess (p. 282) ; elsewhere 

 it is lifted off by the related viscera. 



Excision of the Right Kidney may require to be performed 

 from the front, when the viscus is too large to be removed 

 through the loin. A long vertical incision is made through 

 the anterior abdominal wall, commencing above at the tenth 

 costal cartilage. Owing to the length of the wound, the ninth, 

 tenth, and eleventh intercostal nerves have to be sacrificed as 

 free access is essential. The abdominal cavity having been 

 opened, the peritoneum is incised along the upper part of the 

 right paracolic gutter and the hepato-renal recess. It is carefully 

 stripped off the hepatic area, and the ascending colon, right 

 colic flexure, second part of the duodenum, and the head of the 

 pancreas are turned medially. In this way the anterior surface 

 of the kidney is exposed, and the pedicle formed by the renal 

 artery and vein can be defined by careful blunt dissection. 

 The vein is the most anterior structure at the hilum and the 

 ureter and its dilated pelvis the most posterior, while the artery 



