The abdominal incision is now extended downward to the pubis. The first and second fingers of the left hand are introduced into the peritoneal cavity and used as directors to lift up the abdominal wall and to keep the intestines from the knife, the latter cutting between them in the line of the first incision through the skin and subcutaneous fascia. When the main incision is complete the knife is introduced into the abdominal cavity with cutting edge directed outward and the abdominal muscles are divided on either side just above the pubis by cuts extending outward to the skin. (See Fig. 36.) Care should be taken not to cut the latter. These transverse cuts made from the peritoneal surface permit the opening of the peritoneal cavity to the necessary extent, so that transverse incisions through the skin are not necessary. The main incision is carried to the left of the umbilicus and then back to the median line, in order not to injure the umbilical vessels, the ligamentum teres of the liver, or a concealed hernia or persistent omphalomesenteric duct. In the case of the new-born the incision to the left of the umbilicus is extended to the pubis in an oblique line diverging from the median line. After the examination of the umbilical vessels through the main incision a second diverging cut is made from just above the umbilicus, passing to its right, across the umbilical vessels and hepatic ligament down to the pubis, forming a triangular flap including the umbilicus, urachus and umbilical arteries. The abdominal flaps are now held back and a thorough inspection of the cavity made, noting particularly the position of the abdominal organs, contents of cavity, condition of peritoneum and appendix, occurrence of perforations, etc. The position of the diaphragm is then determined on both sides, by passing the right hand up under the ribs to the highest part of the dome of the diaphragm and then pressing outward against the chest-wall so that the height can be estimated by rib or interspace.