. Manual of operative surgery. ites: Theabdominal incision, instead of being made over the normal location of the gall-bladder, is made high and close to the mid-line, usually extending to the ensi-form. Through this high incision, in most cases, much of the right lobe of theliver .can be rolled out by using the gall-bladder as a tractor. If the liver 572 OPERATIONS ON THE BILIARY PASSAGES is adherent to the parietal peritoneum, the adhesions should h>e freed before pro-ceeding further, as the operation is much simpler if the liver can be displaced. Step 2.—Explore the common duct, the head
. Manual of operative surgery. ites: Theabdominal incision, instead of being made over the normal location of the gall-bladder, is made high and close to the mid-line, usually extending to the ensi-form. Through this high incision, in most cases, much of the right lobe of theliver .can be rolled out by using the gall-bladder as a tractor. If the liver 572 OPERATIONS ON THE BILIARY PASSAGES is adherent to the parietal peritoneum, the adhesions should h>e freed before pro-ceeding further, as the operation is much simpler if the liver can be displaced. Step 2.—Explore the common duct, the head of the pancreas and the neigh-boring lymphatic glands. The dissection necessary for this exploration exposesthe cystic duct. Step 3.—Apply a forceps to the fundus of the gall-bladder and gently pullit forwards and upwards. Apply a second forceps to the neck of the \ascus;traction on this pulls the cystic duct away from the liver. By blunt dissectionclear away any fatty and cedematous tissue which obsctires the duct. Using. Fig. (Judd, Annals of Surgery.) the cystic duct as a guide expose its junction with the common duct. Theneck of the gall-bladder and the lowest part of the body of the gall-bladderfrequently lie along side the cystic duct, so that when this is dissected outand pulled up, the cystic duct is easily separated from the surface of the liver(Fig. 702). Step 4.—Isolate the cystic duct and the cystic artery together for about ^or I inch and doubly clamp them together. Divide between the clamps. Step 5.—Make traction on the forceps applied to the cystic duct besidethe gall-bladder and so make prominent the peritoneal folds attaching the CHOLECYSTECTOMY 573 bladder to the liver as well as the communicating vessels which are now easilycontrolled. Dissect the gall-bladder from the liver, leaving however enough ofits fundus attached so that it can be used as a tractor during the next step of theoperation (Fig. 703).
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