The Abdomen 139 



line corresponding to the contemplated incision. There is no danger 

 of piercing the bowel with a blunt director, and if any portion of . 

 the former should be caught up it is perceptible through the wall 

 as a slight elevation. In that case the director is withdrawn far 

 enough to release the gut and again passed. With the director 

 as a guide, the incision in the muscle wall is made with a bistoury. 



Any vessel being divided, it is grasped with hemostatic for- 

 ceps, which generally suffices to arrest the flow within a minute or 

 two. The epigastric vessels should always be ligated. All hem- 

 orrhage being under control, the peritoneal coat may be picked up 

 with the dissecting forceps and pierced with the scalpel, or it may 

 be gently incised in situ, and the opening enlarged with the finger. 

 Beneath is found the omentum major, excepting just in front of the 

 pubic border. It may be gently pulled away from the hypogastric 

 region and stowed away in the epigastric, or an opening may be 

 made in it by tearing at a point opposite the incision. 



The viscera are now exposed to view, and the necessary sup- 

 plemental operations demanded by the exigencies of each par- 

 ticular case are immediately undertaken. 



There is generally some tendency to protrusion of intestinal 

 coils. This must be guarded against as much as possible, though 

 it is rare that any evil effects follow prolonged exposure. It may 

 be prevented by temporarily inserting flat sponges or small cloths 

 (sterilized) just within the wound. The radiation of heat 

 incident to prolonged exposure tends to lower the vitality of the 

 peritoneum, whereby its eliminative or absorptive power is checked. 

 Vincent in his experiments found that there was more likelihood 

 of peritonitis developing after exposure of the bowel, and regarded 

 it as important not to let any escape. Should it be necessary to allow 

 of any considerable protrusion of viscera it is advisable to carefully 

 protect the exposed organs with sterile gauze wrung out in hot 

 water and repeatedly applied. It is a good plan, when an opera- 

 tion is likely to last a considerable time, to employ a "celiotomy 

 cloth." This consists of a piece of cloth with a slit in it made to cor- 

 respond with the skin incision, and sterilized. It is laid over the 

 abdomen, and thus prevents contact of protruding organs with the 

 skin. A full bladder, which is often an interference, may be 

 emptied by direct pressure. 



The pelvic cavity is opened by extending the skin incision to 



