840 
DEPARTMENT OF SURGERY. 
angle of the ilium and the posterior border of the last rib. In 
every case the condition of the kidney should be ascertained 
before the incision is enlarged, and if the condition can be 
properly treated by nephrotomy it should not be removed ; but 
if there is any doubt as to its efficiency, the proper method to 
adopt is to remove the entire kidney. The line of the secon¬ 
dary incision is not of much importance, any direction that 
will give the operator plenty of room will answer the purpose, 
providing that it does not enter the peritoneal cavity. When 
the incision has been enlarged and all haemorrhage arrested the 
hand should be passed close to the capsule to separate it from 
the circumrenal fat ; if adherent it may require the use of a 
knife or scissors. When the kidney has been loosened from its 
surrounding tissue, the blood vessels must be ligated ; they may 
be ligated separately or in a body including the ureter. If the 
kidney is large, a temporary ligature may be applied and part 
of it removed in order to make room for the purpose to ligate 
the vessels properly. If it is possible to ligate them without 
including the ureter it should be excluded, and when the blood 
vessels have been substantially ligated the kidney should be 
removed by cutting the vessels at a safe distance from the liga¬ 
ture. The pedicle should be carefully examined and properly 
trimmed ; the wound irrigated, all haemorrhage arrested, and 
the incision closed and carefully drained. 
Ceho-Nephrectomy or Abdominal Nephrectomy .—The inci¬ 
sion can be made along the linea alba or a little to one side of 
it, depending upon the kidney involved. The length of the 
incision should be about io cm., just large enough to admit the 
hand to make an examination ; the centre of the incision should 
be near the umbilicus. The incision may be enlarged to suit 
the condition ascertained by the examination. The intestine 
must be kept to one side by the use of sponges ; a small incision 
is made into the peritoneum over the kidney, which is enlarged 
with the fingers and the kidney separated from the surrounding 
fat. The ureter is ligated and cut, when the blood vessels may 
be ligated collectively and the kidney removed with a pair of 
scissors. The cavity must be thoroughly cleaned, and all the 
sponges and instruments removed. The operator must count 
all articles used for the operation before and after the operation. 
The cavity is closed as in celiotomy. The ventral incision is 
preferable in removing a floating kidney or an enlarged tume¬ 
fied kidney. After-treatment is the same as in celiotomy. 
(vSee Celiotomy, Dept, of Sur., Review.) 
