350 THE ABDOMEN AND PELVIS 



occupies an intermediate position. The ureter is ligated in two 

 places and divided. Next a ligature is passed round the vascular 

 pedicle and the artery and vein may then be ligated separately 

 nearer to the kidney. The viscus is removed, after it has been 

 separated from the surrounding peri-nephric fat. 



In advanced tuberculous disease and hydronephrosis the 

 vascular supply may be much diminished, and it may be im- 

 possible to define the vascular pedicle owing to the presence 

 of adhesions. Care must be exercised in these cases not to exert 

 traction on the kidney, because the right renal vein, which is a 

 short vessel, may tear away from the inferior vena cava. This 

 risk can sometimes be avoided by splitting the capsule and 

 shelling out the kidney from inside. The bleeding vessels can 

 be secured as they are encountered, and subsequently portions 

 of the capsule can be cut away. 



The Left Kidney is crossed at about the middle of its 

 anterior surface by the pancreas and splenic vessels (Fig. 87). 

 Above the pancreas, the left kidney is related to the spleen, 

 laterally, and to the suprarenal gland, medially. The area 

 between these two viscera lies in the posterior wall of the 

 omental bursa and forms a part of the stomach bed. Below the 

 pancreas, the first coil of the jejunum covers the whole surface 

 except a strip along the lateral border, which is in contact with 

 the left colic flexure and the descending colon. 



The peritoneum is lifted off the kidney by the descending 

 colon, the pancreas, and the suprarenal gland, which are all in 

 direct contact with the viscus. The lieno- renal ligament 

 reaches the kidney above the pancreas, and its right layer is 

 continued over the gastric area, while its left layer covers the 

 area in contact with the spleen (Fig. 87). The area related 

 to the jejunum is covered by the downward continuation of the 

 lower layer of the transverse meso-colon. 



It should be noted that the left kidney is found in three 

 regions, viz. (i) the omental bursa, (2) the left infra-colic 

 compartment, and (3) the lieno-renal recess, at the upper end 

 of the left paracolic gutter. 



Excision of the Left Kidney is carried out by a method 

 very similar to that adopted for the right kidney. After the 

 abdominal cavity has been opened, the peritoneum in the upper 

 part of the left paracolic gutter, the phrenico-colic ligament, 

 and the peritoneum along the upper part of the lateral border 

 of the kidney are all incised. The descending colon and left 



