A Review of Duodenal Surgery

THE DUODENUM AND ITS SURGERY. APPLIED ANATOMY. I HE duodenum is one of the inost interesting of the abdominal viscera; it is linked up with numerous pathological conditions, and is of interest to the physician, the surgeon, and the pathologist. Developmentally it inay be the seat of an atresia, or it may show diverticula along its pancreatic border, especially in the region of the ampulla of Vater, but it should be noted that these diverticula are never foundl in the first part. Its relation to the vertebral column renders it liable to traumatic rupturc, where the third part may be crushed against the lumbar vertebrae, and its relation to the superior mesenteric vessels suggests the possibility of conmpression of the third part andi dilatationl of the portion lying on its oral side. The gall-bladder and duodenum are intimately related. 'l'he second part lies in contact with the gall-bladder, and here adhesions may form, an abscess may develop, gallstones may be discharged intraperitoneally or into the duodenum, andcl fistulw may develop between the viscera or betw-ecen the viscera and the abdominal wall. The common bile-dluct (lescen(ls behinldI the first part anid medial to the second part, finally opening at the ampulla of Vater, four inches from the pylorus. TIhe (luct may be blocked by a stone, the removal of which may require mobilization of the second part, or may lead to a transduodenal choledochotcwny. Anastomosis of the gall-bladder to the sCcoI(1 part is indicated for common duct obstruction by pancreatic tumour, whilst a tumour of the bile papilla may be removed locally, or may justify a free removal of the second part and an implantation of the common duct into the first part. Apart from these anatomical relations, easily visualized and easily explained, there are other links between the two viscera, such as the combination of chole-cystitis and duodenitis, the occurrence of gastro-duodenal haemorrhage after gall-bladder operations, pylorospasm secondary to gallstones , and duodenal symptoms relieved by cholecystectomy. These, perhaps, fall into the zone of applied physiology rather than that of applied anatomy. Although the duodenum is exceedingly well supplied by blood-vessels derived from the hepatic and superior mesenteric, there is only one vessel of applied 20