Fig- 133- Sub-Phrenic Space: Pelvis of Ureter, Hilum of Liver; 



Bile Ducts. 



Sagittal Section passing I'^lath indies to the right of the middle line of a 



frozen female body. The Common Bile Duct was exposed in its course behind 



the Duodenum and Pancreas. The Peritoneum is in red. 



This figure shews with great accuracy the course of the Common Bile 

 Duct which is usually 3 to 4 inches long. Its upper portion — Supra-Duodenal 

 Portion — lies within the Peritoneum of the Hepato-Duodenal fold, and is 

 iY;,th inch long. 



The Duct next passes behind the upper part of the Duodenum and 

 crosses it — Retro-Duodenal Portion i inch long. 



The last portion — Pancreatic Portion — i Y^th inch in length , runs 

 either through the substance of the Pancreas or in a groove on this gland to 

 the left side of the descending portion of the Duodenum where it opens into the 

 Ampulla of Vater close to the Pancreatic Duct, or together with it in some cases. 

 The Retro-Duodenal and Pancreatic portions are both retro-peritoneal. (Cf. Fig. 136.) 



This is of importance in operations on the Bile Duct (gall-stonesj ; the most 

 easily accessible part is the Supra Duodenal portion. (Cf. Fig. 132, text.) 



To expose the Retro-Duodenal portion the Gastro-Hepatic Omentum must 

 be divided at the upper portion of the Duodenum, and this structure drawn 

 downwards. When the upper and descending parts of the Duodenum have been 

 freed and drawn to the left, the Pancreatic portion of the Duct is accessible (Trans- 

 duodenal Choledochotomy). Cf. Fig. 129. Exposure of the Retro-peritoneal portion 

 of the Duct from the back, as practised b}' Tuffier, is less commendable. Rupture 

 of this portion of the Duct leads to extensive retro-peritoneal exudation of Bile. 



The organs below the Diaphragm, viz. Liver, Spleen, Stomach, are separ- 

 ated by a narrow space from the Diaphragm, which is lined by Peritoneum, and 

 communicates with the Abdominal Cavity: this does not apply to those parts of 

 the Liver (cf. Fig. 131) which are not covered by Peritoneum but connected with 

 the Diaphragm by loose connective tissue. When pus spreads into this space from 

 neighbouring organs; Stomach, Gall-Bladder, Appendix, Kidney, or in general 

 Peritonitis, a Subphrenic abscess is formed. 



Accordingly, a Subphrenic abscess ma}' be either Intra- or Extra-peritoneal ; 

 the latter variety is very Ukel}' to occur if suppuration extends along the perinephric 

 connective-tissue. (Cf. Figs. 133 and 136.) 



