. Diseases of the gall-bladder and bile-ducts, including gall-stones . art; if there be no tumour, but an enlarged liver, theupper end of the incision will have to commence at thehepatic margin. If, however, as is so often the case, therebe neither tumour nor enlargement of the liver, the incisionwill be from the ninth costal cartilage, vertically downwardfor 3 inches. The aponeurosis in the semilunar line may be divided,but, as a rule, the fibres of the rectus may be separated, andthe anterior and posterior layers of the rectus sheath willthen be separately cut. If more room be required, it c
. Diseases of the gall-bladder and bile-ducts, including gall-stones . art; if there be no tumour, but an enlarged liver, theupper end of the incision will have to commence at thehepatic margin. If, however, as is so often the case, therebe neither tumour nor enlargement of the liver, the incisionwill be from the ninth costal cartilage, vertically downwardfor 3 inches. The aponeurosis in the semilunar line may be divided,but, as a rule, the fibres of the rectus may be separated, andthe anterior and posterior layers of the rectus sheath willthen be separately cut. If more room be required, it can be 174 DISEASES OF THE GALL-BLADDER AND BILE-DUCTS obtained either by extending the vertical incision or addinga transverse one, either internal or external to the verticalline, in whichever direction it may seem advisable. It isdesirable to avoid, as much as possible, dividing muscularfibres, as they retract and can only with difficulty be approxi-mated in suturing the wound. Another great advantage inthe vertical incision is the avoidance of vessels and ORDINARYINCISION. -I— Kochers OBLIQUEINCISION. Fig. 44.—Diagram to show Incisions. The transversalis fascia and peritoneum are best dividedtogether, without separating them, as together they form astrong membrane, whereas singly they are too weak to holdstitches if there be much tension. Kocher employs an oblique incision parallel to the rightcostal margin (Fig. 44), which of necessity divides musclesand nerves, but which exposes the parts freely, as the woundat once gapes widely. Although for cholecystotomy the transverse or oblique GALL-STONES, OR CHOLELITHIASIS 175 incision is quite unnecessary, and usually inadvisable,where it is necessary to expose or manipulate the commonduct it presents the advantages of better exposure and moreefficient drainage, though for drainage of the right renalpouch a stab wound in the loin is both simple and lumbar incision, which has been suggested in order toreac
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