. Operative surgery, for students and practitioners . indicated in some cases of chronic non-malignant ulcera-tion involving the pyloric portion of the stomach. The incision is placed in the middle line and should be suffi-ciently large, 10 to 15 cm., extending from the ensiform processdown to the umbilicus or beyond this point. The pyloric end of thestomach is drawn into the wound and well surrounded with gauzepads so arranged as to protect the abdominal cavity during the op-eration, and the left lobe of the liver is held up out of the way byan assistant. Billroths First Method.—The first ste
. Operative surgery, for students and practitioners . indicated in some cases of chronic non-malignant ulcera-tion involving the pyloric portion of the stomach. The incision is placed in the middle line and should be suffi-ciently large, 10 to 15 cm., extending from the ensiform processdown to the umbilicus or beyond this point. The pyloric end of thestomach is drawn into the wound and well surrounded with gauzepads so arranged as to protect the abdominal cavity during the op-eration, and the left lobe of the liver is held up out of the way byan assistant. Billroths First Method.—The first step in the operation is thedetachment of the pylorus (diseased part to be excised) from thegreater omentum (transverse colon) below and from the lesser omen- 268 ABDOMEN AND BACK. turn above. With a blunt-pointed ligature carrier, armed with catgutor fine silk, the greater and lesser omenta, corresponding to the dis-eased pylorus, are transfixed and tied off in sections. Each ligatureshould include from one to one and one-half inches of the omentum,. Fig. 114.—Pylorectomy. Anterior edge of the liver is lifted up; the lesserand greater omenta are shown. The lesser and greater omenta, correspond-ing to the portion of the stomach that is to be excised, have been ligated insections. The dotted lines indicate the line of section through the stomachand omenta. Instead of being applied as represented in this picture, theligatures may b€ placed double and the line of incision carried between them. and should be applied double so that when the operator divides eachsegment of the ligated omentum, he may do so between the two ligatures will suffice for the lesser omentum, gastro-hepatic ligament, and three or four for the greater omentum, gastro- OPERATIONS UPON THE STOMACH. 269 colic ligament. Instead of a ligature carrier a sharp-nosed artery-forceps may be used to pass the ligatures. One should be mindfulof the location of the common bile-duct and the portal vein
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