. A manual of operative surgery . are singularly to the pancreas, leakage of bile into the subperitonealtissues, troublesome haemorrhage, are three dangers of thismethod. Moreover, should calculi lodge in this portion ofthe duct they can be reached by forceps or a scoop fromabove, or can be pushed upwards by manipulation with thefingers. A calculus is more often impacted in the ampulla than inthe second part of the duct. Fig. 43 shows such a case, andthe relation of the papilla to the fold of duodenal mucous mem-brane above it. In this position the best operation is certainlyto appr
. A manual of operative surgery . are singularly to the pancreas, leakage of bile into the subperitonealtissues, troublesome haemorrhage, are three dangers of thismethod. Moreover, should calculi lodge in this portion ofthe duct they can be reached by forceps or a scoop fromabove, or can be pushed upwards by manipulation with thefingers. A calculus is more often impacted in the ampulla than inthe second part of the duct. Fig. 43 shows such a case, andthe relation of the papilla to the fold of duodenal mucous mem-brane above it. In this position the best operation is certainlyto approach the duct through the second part of the duodenum,as first suggested and carried out by McBurney of New Yorkin 1891. i66 ABDOMINAL OPERATIONS [PART II TRANSDUODENAL CHOLEDOCHOTOMY If, after opening the abdomen for biliary obstruction, thesurgeon finds a firm lump to the inner side and posterior aspectof the vertical part of the duodenum, it is almost certainlydue to one large stone in the ampulla or to a collection of smaller. TERZl FIG. 48. —ARTERIAL SUPPLY OF STOMACH AND DUODENUM, ETC. {After Testut.) The site of incision for transduodenal choledochotomy is where the letters G. E. D. (gastro-epiploica dextra artery) are placed on the duodenum. The incision through the duodenalwall should, however, be vertical in the axis of the bowel, p. D. A., the pancreatico-duodenal arteries, which form an arch in the hollow of the duodenum, may cause bleedingin this operation, s, Stomach, cut across; p, Pancreas; D, Duodenum; A, Aorta;G. B., Gall-bladder; H. A., Hepatic artery; c. A., Coronary artery of stomach ; s. A.,Splenic artery; G. E. S., Gastro-epiploica sinistra artery; 1. M., Inferior mesenteric. ones. Induration of the pancreas may simulate a stone, butin that case the hardness is usually more diffuse. To reach calculi in the ampulla an incision one to two incheslong is made through the front of the vertical part of the duo-denum. Gauze-pads should be placed around and bel
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