6/4 SURGICAL TECHNIC

case, however, the careful sponging with sterilized moist gauze pads is
better.

1. The external incision is made as long as seems necessary for the
operation, preferably /;/ the linea alba ; if the incision extends above the
umbilical region, the umbilicus is circumscribed on the left side. According
to the organ which the operator desires to reach, incisions can also be made
laterally from the linea alba along the external margin of the irctus abdoini-
jiis muscle, or through its fibres. Under some circumstances, oblique or
transverse ineisions may become necessary.

By making the incision in the median line after division of the skin and
the underlying adipose layer, tJie zuhite shilling linea alba is first reached.
If fibres of the rectus abdominis are reached, in case the incision has not
been made exactly in the median line, the margin of the sheath of the
muscle is sought by the use of a probe ; by this means, the linea alba is
located.

2. After its division, the layer of subperitoneal adipose tissue, more or
less thick, in most cases is exposed; then the delicate, almost transparent
peritoneum.

3. After all hemorrhage has been carefully arrested, a fold of the peri-
toneum is raised between two dissecting forceps and incised with knife or
scissors ; at once, a broad, flat, grooved director is introduced, and upon it
the incision is enlarged far enough for the operator to penetrate into the
abdominal cavity with two fingers of the left hand ; while these protect the
intestines, the peritoneum between them is incised to the extent of the external
incision.

4. The margins of the peritoneuni are stitched to the external skin by
interrupted sutures placed at a distance of about 5 centimeters from each
other ; their ends remain long.

The hand can then be introduced into the abdominal cavity, and the
necessary operations can be performed.

The reunion of the wound must be made very carefully. If it is necessary
to finish the operation rapidly, first several deep sutures are inserted embracing
all of the tissues of the margins of the wound, and the skin between these
sutures is united by several superficial catgut sutures. But, for the purpose
of securing a firm and lasting union, the " e'tage'' or buried suture is made
use of ; first, the serous surfaces of the peritoneum, next, the overlying
parts, fascia or muscle, are united by interrupted or continuous sutures with
catgut (or silver wire, Schede), and, finally, the margins of the skin are closed
by sutures applied alternately with catgut and silk. (The best suturing



OPERATIONS ON THE ABDOMEN 6/5

materials are : for the peritoneum, fine catgut sutures suffice, the deep inter-
rupted sutures, including all other tissues except the peritoneum, are used,
the fascia of the recti muscles is united with catgut, and the skin with horse-
hair sutures.) Draiiiage in the form of rubber or glass tubes or iodoform
wick is established only when an infection of the abdominal cavity has
occurred. In such cases, it is even advisable not to suture the wound at
all, in order to relieve the abdominal cavity from pressure and to secure the
escape of the exudates. Israel, in diffuse, purulent peritonitis, made an ex-
tensive crucial incision through the abdominal wall, and left it open ; an
apron of sterilized muslin is inserted in front of the intestines. After some
time, they retract into the abdominal cavity of their own accord.

If, during the operation (for instance, after the removal of very large
tumors), a '' dead space'' has been created in the abdominal cavity, from the
walls of which a secondary hemorrhage might easily ensue, it is tamponed,
according to JMiculicz, by packing it with a large piece of iodoform gauze.
This gauze bag is then filled with sterilized gauze, the ends of which are
brought out from an angle of the laparotomy wound, sutured except at this
angle. This gauze is gradually drawn from the cavity, which is thereby
slowly decreased in size and closed.

The dressing can be applied either with iodoform collodion or with iodo-
form gauze, cotton, or strips of adhesive plaster. Moderate compression of
the abdomen by a broad bandage and compression by sand bags placed
upon it are advantageous.

If violent vomiting occurs after the operation, caffeine injected or tinc-
ture of opium or ice pellets administered are sometimes very effective. If
vomiting is very violent, irrigations of the stomach by siphonage may be
advantageous.

In the after-treatment, the nourishment is of the greatest importance,
since after operations on the stomach and intestine, only such nourishment
must be given as is easily absorbed and' does not cause irritation. Some-
times, for the first days, nourishment must be administered "per rectum."
The modern food preparations make it possible temporarily to supply a
sufficient quantity of nourishment to the system by the stomach. For
milder cases, the following simple bill of fare may be sufficient : —

On the day of the operation : The mouth is washed out with cold water.

First day : Half a liter of cold milk (one spoonful every hour).

Second day: In addition, a biscuit ("zwieback") in the morning and
another in the afternoon.

Third day : In addition, a soft-boiled ^gg.



6/6



SURGICAL TECHNIC



Fourth day : In addition, wine soup at noon.

Fifth day : In addition, boiled pigeon or scraped meat lightly roasted,
with mashed potatoes or boiled rice.

Sixth day : From now on, daily, somewhat better and lighter food can
be given — in addition, from the beginning, wine (champagne) may be taken.
TJic dressings are generally removed on the tenth or twelfth day; the
patient is dismissed during the third week after the operation.

(In all abdominal operations the editor makes it an inflexible rule to con-
iine patients to bed for at least four weeks.)

Every patient that has had laparotomy performed must wear an abdomi-
nal supporter in order to avoid a retraction of the margins of the wound
(abdominal hernia, Fig. 1256).

For examining the abdominal organs, BardenJieuer
recommended the extraperitoneal explorative incision,
ivithont invading the peritoneal cavity, in order to
palpate the intestines through the thin parietal peri-
toneum {diaperitoneal). For this purpose, he makes
very large incisions down to the peritoneum, from
which he detaches to a wide extent the abdominal
wall in the form of a door (leaves of a door). Start-
ing from a sacrolumbar incisioji along the anterior
margin of the iliocostalis, he makes transverse inci-
sions either above on the costal arch or below along
the crest of the ilium [liwibar, costal, iliac, door inci-
sion). To reach the organs of the small pelvis, he detaches the abdominal
wall by a transverse incision at a varying distance from the anterior superior
margin of the pelvis {snprasympkysis incisioji).




Fig. 1256. Abdominal Sip-
porter after lapa-
ROTOMY



LAPAROTOMY FOR ILEUS



In ileus caused by mechanical intestinal obstruction (foreign bodies,
neoplasms, cicatricial stricture, invaginations, intussusceptions, volvulus,
retention by bands, etc.), if internal remedies have not yielded any relief, lapa-
rotomy is indicated; if, however, septic intestinal paralysis has already set
in, — that is, if no single floating intestinal loops can be any longer distin-
guished in the barrel-like swollen abdomen, — and if the patient is almost
exhausted, it is important, first of all, to secure an evacuation for the accu-
mulated putrefied intestinal contents {enterostomy, see page 697). For this
purpose, a place is selected as nearly above the obstruction as possible. By



OPERATIONS ON THE ABDOMEN 677

i^civs, preliminary operation, the obstruction itself is sometimes removed per-
manently; else the radical operation may be performed subsequently, when
the patient has regained his strength.

If the operator is sure of the exact location of the seat of the obstruction,
he should make the incision for laparotomy preferably above the obstmctton.
If, however, the same is unknowm, the incision is made iji the linea alba.

The seat of the obstruction must then be sought ; the hand, introduced
into the abdominal cavity, seeks to ascertain the seat and the cause of the
obstruction by palpating the intestines as far as possible. If this is not
successful, tJie intestine must be exventrated ajid examined. An assistant
seizes any of the markedly inflated loops of intestine lying in the abdominal
wound, and holds it securely all the time ; proceeding from the same, the
operator continues to ex\^entrate other loops, which the assistant returns
directly into the abdominal cavity. If, from the decrease of the inflammjation
and the inflation of the intestinal loops, the operator is satisfied he is receding
from the seat of strangulation, then, on the other side of the intestinal loop,
firmly held by the assistant, the operator proceeds in the same manner until
the obstruction is reached {Hulke, Miciilicz). The obstruction is most
promptly found, however, when the operator, " a priori," makes a verv" long
external incision. The intestines are received and placed in a hot compress
{Kiimmell). On account of the rapid cooling of the intestines, the greatest
speed is imperative in adopting this procedure.

If the operator finds an invagination, or if an intestinal loop has passed
through an opening in the mesentery, the attempt should be made to liberate
the same by traction ; bands are divided after previous double ligation. If
he finds neoplasms, the intestinal portion involved must be resected, or
anastomosis must be established. If he finds a volvulus caused by elonga-
tion of the mesentery, the intestine must be replaced into its normal position,
and the mesentery must be shortened by forming a fold running parallel to
the intestine ( Senn); the sigmoid flexure, reduced into its normal position, is
sutured to the left abdominal wall ivon Niissbaiim ).

After removal of the obstruction, the intestines must be returned into the
abdomen as rapidly as possible, — a procedure that may become extremely
difficult, on account of the distention of the intestines.

By returning them slowly into the abdominal cavity and by gradually
diminishing the external wound by suturing, this procedure can be accom-
plished ; but it is not advisable to employ too much force, because, as a rule,
the fatal collapse sets in rapidly, and, notwithstanding the removal of the
obstruction, the paralyzed intestine cannot transport its decomposed contents.



6/8 SURGICAL TECHNIC

If the intestine is not yet paralyzed, the peristaltic movements of its
musculature often facilitate its reduction ; also, by irrigating the stomach
with an open abdominal cavity {Rc/ui), more space can be created, and the
return can be facilitated. In case of greatest necessity, the distended ex-
posed intestinal loops must be incised at one place by a longitudinal incision,
and the contents must be stripped out with the fingers, or are allowed to flow
out gradually through a drainage tube fastened into it {Miciilics). If the
reduction is successful after this, the visceral wound can be closed by enter-
orrhaphy ; but if the intestines are paralyzed, it is better to fasten the loop
in the external wound, and thus establish an artificial anus (see page 289).



OPERATIONS ON THE STOMACH AND THE INTESTINES

GASTROTOMY

The scientific openi7ig of the stomach is made for removing foreign bodies
which have been swallowed and which, on account of their shape and quality,
cannot be expected to pass spontaneously. By incising the stomach, as
early as 1635, Daniel Schwab successfully removed a knife that had been
swallowed. If abscesses or adhesions with the abdominal walls are present,
a simple incision suffices ; otherwise, the method is as follows : —

1. External incision either from the tip of the ensiform cartilage ob-
liquely to the left, a thumb's breadth below and along the left costal arch ;
or beginning in the median line, in the linea alba, a thumb's breadth below
the ensiform process. Incision and stitching of thQ perito?iaim to the skin
(see page 675).

2. The stomach is drawn forward with the two fingers; the anterior wall,
if necessary, is held by two ligature loops passed only through the serous and
the muscular coats.

3. The stomach is then opened, preferably, by a vertical incision, for the
purpose of avoiding large blood vessels (gastric artery), either directly over
the foreign body, if it can be felt, or in the free space between the Hgature
loops.

4. If the opening is sufficiently large, the foreign body is extracted with
the fingers or forceps, and the opening is closed by gastrorrhaphy, in which
the ligature loops can be used. In recent times, gastrotomy has also been
made for gastrorrhagia and gastric ulcers. After the stomach has been
opened, the bleeding vessel can be sought for, and ligatcd ; ulcers are
excised, and the fresh wound surfaces are united by suture {Rydygicj-).



OPERATIONS ON THE ABDOMEN 679

(In the surgical treatment of gastric ulcers, U\ Audrezi's of Chicago
raises a cone on the inside of the stomach with the ulcer as its apex, ap-
plies a ligature at its back, and amputates the tissues on the gastric side of
the point of ligation.)

GASTRORRHAPHY

is indicated : —

(a) In wounds of the stomach.

(d) \xi gastric fistulas caused by ulcers or injuries. (From punctured or
incised wounds, the stomach in most cases prolapses, so that nothing of its
contents reaches the abdominal cavity ; if this is the case, fatal peritonitis
rapidly ensues.)

According to Lemberfs metJwd (Fig. 1310), the suture passes only
through the serous and the muscular coats ; the margins of the woitnd are
inverted either by interrupted sutures or by rectangular continuous suture
(see page 703).

Contused portions of the margins of the wound are vivified, if necessary ;
in gastric fistulas, the fistulous margins must be excised and their cicatricial
surroundings must be removed prior to the insertion and tying of the
sutures.

Gastropexy is an operation which has for its object the stitching of the
stomach to the opened anterior abdominal wall by sutures passing through
its serous and muscular coats.

Poncet makes it directly after stenoses of the oesophagus, that he may
subsequently be able to open the stomach in case of necessity more easily at
the place where it has become adherent to the abdominal wall. It can also
be resorted to in elevating the stomach dislocated downward {gastroptosis).
BircJier, Weir, Brandt, and others have, by gastroplication, successfully
diminished the size of the stomach, when greatly dilated and when this con-
dition resisted the usual treatment. The exposed anterior wall of the
stomach is folded inwardly in the direction of the long axis of the organ
with a probe, and the wall of the stomach is sutured over it, the sutures
passing only through the serous coat. With several rows of buried sutures,
a fold as broad as the hand and extending into the interior of the stomach
can be formed and permanently retained. In the same way, several longi-
tudinal folds can be made on the anterior and the posterior side. Similar
is Tricomi's gastrostenoplasty. Von Hacker designates the operation of
separation of adhesions and bands that often cause violent gastralgias, gas-
trolysis.



68o SURGICAL TECHNIC

GASTROSTOMY {Se'dil/ot, 1 849)

an operation for establishing z. fistulous opening into the stomach tluvugJi the
abdominal xvalls, is made : —

{a) On account of stricture or obstruction of the cesopJiagns from ulcers
or cicatrices situated so deeply that they cannot be reached from a wound
in the oesophagus.

ib) On account of large diverticula of the oesophagus.

(<:) For the removal oi foreign bodies firmly impacted in the same.

If, on percussion, the stomach is found to be very much contracted, —
as it is in most cases, — it is advisable, if at all possible, to inflate it by
some effervescent mixture shortly before the operation.

1. External incision 7 to 8 centimeters long from the median line and
the ensiform process obliquely to the left downward, parallel to and 2 centi-
meters below the left costal arch as far as the eighth costal cartilage {Fenger),
or vertically 2 to 3 centimeters to the left from the linea alba through tJie
fibres of the rectus abdominis muscle (which, after healing, forms a sphincter-
like closure) {von Hacker).

2. Having incised the peritoneum and stitched its margins to the skin,
the stomach is sought for, which, contracted in most cases, lies deeply
behind. From the course of the gastro-epiploic artery and vein, the wall of
the stomach is discernible, and can be distinguished from the transverse
colon, which, moreover, is covered by the omentum.

3. A fold of the anterior wall of the stomach is drawn forward and
stitched with about fifteen to twenty medium-sized silk sutures (which do

not pass through the entire wall of the stomach,

but only grasp the serous and the muscular coats,

extending about i centimeter in the latter) all

around to the margins of the skin wound, covered

with the peritoneum, so that an oval portion

(about 4 centimeters long and 3 centimeters

wide) of the wall of the stomach forms the floor

of the wound. The long ends of the sutures are

spread all around (in the form of a star), and the

wound is covered with an antiseptic dressing
Fn;. 1257. Gastrostomy (Sutur- /pjp- ioc7\
ing wall of the stomach) ^ °' "-''/■

During the first days, the patient is nourished
with nutrient rectal enemata {Leubes meat solution, tropone, somatose,
etc.). F. Fischer at once administers nourishment by inserting a very fine




OPERATIONS ON THE ABDOMEN



canula obliquely into the stomach, and by injecting milk through the same ;
by making the insertion of the needle obliquely for some time repeated
every day, always at the same place, he establishes an oblique, well-retaining
fistula.

But when the danger of starvation is not very great, then, after three to
five days after the peritoneal surfaces have become adherent with one
another and have intimately united the anterior wall of the stomach to the
abdominal wall, —

4. The opening of the stomach is made. After the dressings have been
removed, the surface of the wound, not clearly distinguishable on account
of the granulations, is lifted somewhat with dissecting forceps or with fine
hooks between the outspread ligature ends, and now a simple or crucial in-
cision is made with the knife or with the thermo-cautery {Hagedorn), just
large enough to admit with some
difficulty a rubber tube having a
lumen of ^ centimeter to i centi-
meter.

If the strength of the patient
has been brought to a low ebb
(from inanition), it is often impos-
sible to wait for peritoneal adhe-
sions and to perform the operation
in tzvo stages ; in such a case the
stomach is opened imm,ediately
after its wall is stitched, and a
tube, through which nourishment
can be at once administered, is
introduced.

Through this tube the patient
takes nourishment, at first cau-
tiously (eggs, scraped meat, pep-
tones, etc.). Later on, the patient's taste and relish for food may be grati-
fied, and at the same time the necessary insalivation and the reflex secretory
function of the stomach may be utilized, by masticating the food and then
conveying it through a tube into the stomach {Trendelenburg, Fig. 1258).

Between meals the tube is closed by a wooden plug ; later on a hard
rubber canula with suitable closure may be employed. If the opening in
the stomach has not been made too large, the canula may be removed entirely
in the interval. By the contraction of the margins of the wound a sufficient




Fig. 1258. Mode of conveying Food to the
Stomach of a Patient who had Gastrostomy
performed



682 SURGICAL TECHNIC

closure of the fistula is then effected, especially if, according to von Hacker,
the opening has been made in the rectus muscle, whereby a kind of sphincter
is formed.

The latter object is obtained still more satisfactorily by Girard' s victJwd.
He makes a vertical incision 15 centimeters long across the middle of the
upper portion of the left rectus muscle, sutures to the middle of this incision
the prolapsed wall of the stomach, detaches at both sides of the opening a
bundle of muscular fibres from the rectus of about a finger's breadth from
the deeper portion of the muscle, and places these two muscular bridges
crosswise one over the other in such a manner as to grasp the sutured cone
of the stomach between them like a sphincter. They are fastened in this
position by sutures.

E. Hahn stitches the stomach in tJie eighth hitcrcostal space in order to
use the elastic costal cartilages like a compression stop-cock, and also to prevent
an enlargement of the fistula. For this purpose he first makes an incision
5 to 6 centimeters long along the left costal arch, about i centimeter distant
from it, and opens the peritoneal cavity to the same extent. He introduces
into the opening a pair of curved dressing forceps, with which the eighth inter-
costal space is perforated from behind upward. Next he cuts down upon
the point of the forceps from the outside. Then, with the thumb and the
forefinger, he draws from the lower wound a portion of the stomach as near
as possible to the cardiac extremity (fundus), grasps it with dressing forceps,
and draws it through the tunnel made m the intercostal space, where it is
fastened by sutures. (Injury to the pleura and the diaphragm need not be
feared in perforating the eighth intercostal space.)

If a cicatricial stricture has contracted the oesophagus, the operator may
attempt to dilate the same from the gastric fistula, first with catgut strings,
and subsequently with a rubber tube passed over a fine whalebone bougie
{yon Hacker) and with the common bougies. After the stricture has been
sufficiently dilated (see also page 641), the gastric fistula can be closed.

But in case of a malignant stenosis that cannot be removed, the patient
is considerably relieved by establis/iing an oblique fistula according to JVitcel
or Frank.

Witzel sutures the wall of the stomach over a little rubber tube, so that
it forms tivo longitudinal folds. This procedure forms a rcrw^?/, the course
of which resembles the lower extremity of the ureter in the wall of the
bladder.

I. External incision a finger's breadth below the left costal arch and
along the same as far as the sheath of the rectus.



OPERATIONS OX THE ABDOMEN



683



2. The sheath is opened by a longitudinal incision; the fibres of the
rectus are divided bluntly and longitudinally in the middle.

3. With the knife and the tip of the finger, the operator passes through
the transversalis abdominis obliquely from the right to the left, down to the
peritoneum.

4. The peritoneum is opened ; next, by a quiet, steady, somewhat pro-
longed traction, a sufficiently large portion of the anterior wall of the stomach
is drawn forward, and on it are raised two oblique folds extending from the
left to the right upward to a distance of i-| to 2 centimeters.

5. At the lower extremity of this groove a small opening is made, and a
rubber tube as thick as a pencil is inserted (Fig. 1259).

6. Over this tube, directed upward, the raised folds of the stomach are
sutured to form a canal about 4

centimeters in length by four or five
Lemberfs sutures. A few fine super-
ficial sutures secure the complete
closure of the groove (Fig. 1260).

7. Next follows the stitching
of the stomach to the abdominal
wound, as described on page 681.
Through the fibres of the rectus
and transversalis muscles the rub-
ber tube, carried outward, is grasped
as if by a cross-clamp.

8. The little tube can remain in
position for weeks without escape of
the stomach contents. Subsequently it can be removed, and is introduced
only for the administration of food. The fistula is covered with a gauze pad.

Marwedel modified this method by forming the oblique fistula intra-
parietal between the mucous and the muscular coats. (This operation
should be accredited to Professor E. Andrezi's of Chicago, who first de-
scribed it in the medical press.) After a fold as broad as the thumb has
been formed of the anterior wall of the stomach, its serous and muscular
coats are incised for about 4 to 5 centimeters ; at the lower angle of the
wound the mucous coat is punctured, a thin drainage tube is inserted into
the stomach and fastened with a catgut suture ; next, the margins of the
serous and muscular coats are united over the tube. The tube can be