. A manual of operative surgery . ween the last rib and the crest of the ilium a narrow hardcushion or sand-bag is placed under the loin of the sound side. The surgeon stands by the patients back leaning over thetrunk ; the chief assistant stands on the opposite side, hisduties being to sponge the wound and to press up the kidneytowards the loin when necessary ; an assistant stands on theright of each, whose sole duty is to hold the retractors in thewound. The twelfth rib should be definitely recognised and welldefined. It is occasionally absent or rudimentary, and thenthe pleural sac descends
. A manual of operative surgery . ween the last rib and the crest of the ilium a narrow hardcushion or sand-bag is placed under the loin of the sound side. The surgeon stands by the patients back leaning over thetrunk ; the chief assistant stands on the opposite side, hisduties being to sponge the wound and to press up the kidneytowards the loin when necessary ; an assistant stands on theright of each, whose sole duty is to hold the retractors in thewound. The twelfth rib should be definitely recognised and welldefined. It is occasionally absent or rudimentary, and thenthe pleural sac descends below the eleventh rib, which (unlessthe precaution is taken of counting the ribs from above) may chap, xix] LUMBAR PERINEPHROTOMY 489 be mistaken for the twelfth (see page 495). At the examinationof the radiogram the condition of the twelfth rib should alwaysbe noted and the width of the costo-iliac space. An oblique incision is made across the costo-iliac space. Theupper end of the cut begins half an inch below the last rib at. fT FIG. 135.—OPERATIONS ON THE KIDNEY. A, Incision for exploration, for nephrotomy and nephrolithotomy; b, Additional incision fornephrectomy ; C, Konigs lumbo-abdominal incision for nephrectomy. a, Latissimus dorsi ; b, External oblique ; c, Internal oblique; d, Transversalis ; e, Serratusposticus inferior ; /, Intercostals ; g, Fascia lumborum over erector spinas; h, Crest ofilium ; i, Intercostal nerve and artery ; 2, Twelfth dorsal nerve and lumbar artery. the outer border of the erector spinae. It is continued down-wards and forwards towards a point one inch above the upperextremity of the anterior superior spine of the iliac crest. Itwill suffice if it is at first four and a half inches in length, andit may be enlarged subsequently as required. Other forms ofincision are alluded to in the comment upon the operation(page 494). After the skin, superficial fascia and fat have been divided, 490 ABDOMINAL OPERATIONS [part ii the outer border of the
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