thermo-cautery, if the incision has to be made through the hepatic tissue
lying over the same ; by puncturing it with a Pravas syringe, information
is obtained as to the thickness of the glandular tissue overlying the cyst
OPERATIONS ON THE ABDOMEN
733
wall. The opening is made as large as the skin-incision ; while the fluid
from the secondary cysts oozes out, the finger is introduced deeply and
examines the wall of the primary cyst for any other firmly adhering second-
ary cysts, which are removed with dressing forceps. Next, sufficient irri-
gation (vi^ith sublimate solution) and tamponade or drainage of the cavity of
the wound are made ; the wound closes gradually by granulation from
below, after the wall of the primary cyst has been eliminated.
Instead of the simple incision of the abdominal walls, Lcisrink recom-
mended previous stitching of the cystic sac to the parietal peritoneum by a
few qnilt sntnres, whereby the adhesions would take place sooner and with
greater certainty (fourth to fifth day).
Since an infection of the peritoneal cavity, if the same is not completely
and perfectly shut out from the seat of operation, is to be apprehended
from the dissemination of echinococcus germs, it seems less safe to make the
operation in one sitting {^Lindemann, Laytdau); after the peritoneum has
been opened, the cystic contents are evacuated by aspiration to such an
extent that the cyst wall becomes flaccid ; it is then incised, and the margins
of the incision are sutured to the peritoneum lining the incision.
Traumatic abscesses of the liver are treated according to similar principles.
The resection of portions of the liver for constricted lobe (" Schniirleber ")
caused by constriction of the waist or tight lacing {Langenbnch) and in
echinococci {Loreta) has been made recently with good success ; the hem-
orrhage from the surfaces of the incision must be arrested by acupressure
with round needles or by the thermo-cautery ; also the superior and the infe-
rior margins of the hepatic wound can be sutured together. (Suturing of the
liver as a hemostatic resource is a very unreliable agent, owing to the great
f ragihty and vascularity of the organ. The iodoform gauze tampon is more
effective and serves at the same time as a useful capillary drain when brought
out of the abdominal incision.) Single pedunculated flaps are ligated by
elastic constriction. Even after removal of more than half the liver, the
lost portion is regenerated in a short time {Ponfick).
CHOLECYSTOTOMY
The opening of the gall bladder by incision may be made for biliary calculi,
provided the gall bladder itself is healthy and not very firmly adherent to
its surrounding parts.
I. The incision of the abdominal wall extends along the external margin
of the right rectus abdominis muscle from the costal arch downward {loiigi-
734
SURGICAL TECHNIC
tndinal incision), or it extends as an obliqne incision from the tip of the tenth
costal cartilage inward and downward toward the umbilicus ( Tait\ or it is
made transversely a Httle above or upon the lower border of the liver
[hepatic border incision) {Conrvoisier).
2. After incision of the abdominal wall, the liver, if possible, is turned
over, and the gall bladder is drawn forward into the abdominal wound as far
as possible, and is held firmly by means of a ligature loop passed through it ;
it is punctured with a fine trocar. After its contents have been evacuated,
the cavity is irrigated with a disinfecting solution (boric, sahcyHc).
3. Next, from the place of puncturing, the gall bladder is incised, prefer-
ably transversely, and parallel to the lower hepatic border, until the finger
can be inserted into the cavity.
4. Any biliary calculi present are removed with the finger or the forceps,
retractors, etc. ; concretions firmly lodged in the cystic dnct or concealed in
the pocket-like diverticula of the walls can be pushed upward from the out-
side with the fingers ; or, if necessary, the operator may try to crush them
by pressure.
5. After all the stones have been thus removed, the wound of the gall
bladder is sutured with ''the most painstaking care possible " by a double row
of serous sutures according to Cserny (see Fig. 1 3 1 1 ) ; the gall bladder is then
returned into the abdominal cavity (cholecystendysis, Conrvoisier); or
its sutured part is fastened to the parietal layer of the periosteum
(cholecystopexia).
6. The abdominal walls are likewise completely united by suture.
This so-called ideal cholecystotomy {Bernays) reproduces in the best pos-
sible manner the original normal conditions, but can be resorted to with
safety only when the walls of the gall bladder are healthy ; in inflamed
tissue, the sutures would easily tear out, or leakage might take place from a
subsequent occurrence of inflammatory hydrops. Hence, if in cholelithiasis
the cystic wall is at the same time considerably diseased, and if such firm
adhesions exist that the extirpation of the gall bladder seems not advisable,
and if the operator is not perfectly sure whether calculi remain in the bile
ducts, it is better to perform
CHOLECYSTOSTOMY,
that is, to establish a biliary fistula. After incision of the abdominal wall,
drawing forward the bladder, puncturing and disinfecting its cavity, and
removal of calculi as described above, the opened gall bladder is sutured to
the margins of the abdominal wound. First, its serous coat is united with
OPERATIONS ON THE ABDOMEN 735
the parietal peritoneum all around by sutures applied very closely, in order
to close the abdominal cavity. Next, the mucous membrane of the gall
bladder is sutured to the external skin, and thus a lip-shaped fistula is pro-
duced. Into the same, a short drainage tube or an iodoform wick is
introduced.
In place of tJiis natural cJiolecystostomy {at one sitting) {Lazvson, Tait),
the operation may be made also in two stages (Riedel, Bardenhener) ; first,
the fundus of the gall bladder is stitched unopejicd to the abdominal wound
with sutures, grasping only the walls without injuring its lumen; and, after
a few days, when the adhesions have become firm and the closure of the
abdominal cavity seems to be assured, the opening is made, and the calculi
are removed.
It is true this procedure offers the greatest safety, but it has the disad-
vantage of often creating a permanent suppurating and biliary fistiUa. Its
very long continuance often exerts an unfavorable influence upon the condi-
tion of the patient, especially since further disadvantages are also caused by
stitching the gall bladder to the abdominal wall. If, however, the fistula
closes up (or if it is cured by an operation), conditions for the recurrence of
the original disease have been thereby created (hthiasis).
Hence, Langenbuch (1883) recommended removing all these compHca-
tions and disadvantages with one stroke by
CHOLECYSTECTOMY
The excision of the entire gall bladder is indicated : ā
{a) In vesicular cholelithiasis of long standing and frequent recurrence.
{b^ In dropsy of the gall bladder from obstruction of the cystic duct.
{c) In serious disease of the wall of the gall bladder (empyema, ulcers,
tumors).
{d) In ruptures or zvounds of the gall bladder, which cannot be sutured,
and in biliary fistrdas.
On the other hand, the operation should not be made : ā
{a) In the case of firm adhesions with the surrounding parts, especially
with the Hver.
{b) In obstructions of the common duct, which cannot be removed.
{c) In cases in which many small calculi are present in the bile ducts.
I. A ā \-like incision of the abdominal ivalls. Longitudinal incision 10 to
1 5 centimeters long along the outer margin of the right rectus muscle, upon
which a transverse incision of equal length is made along the lower margin
of the liver.
736
SURGICAL TECHNIC
2. The colon and the small intestines are pushed dowuzvard with a flat
sponge, the right hepatic lobe is drawn upivard so that the hepatoduodenal
ligament, in which the large bile ducts Ue and which can be palpated, be-
comes tense. The ligament is incised; if a calculus is discovered in the
common duct, the operation must not be performed.
3. After the gall bladder has been exposed as far as the cystic duct, the
latter is encircled with an aneurism needle armed with a silk ligature, i to 2
centimeters distant from the hilum of
the bladder, and doubly hgated. If
the operator detects calculi in the
same, they must first be pushed back-
ward in the gall bladder.
4. Next, the gall bladder is de-
tached from its recess in the fissure
of the liver. After its peritoneal cov-
ering has been carefully incised, the
operator easily succeeds in separating
it from the liver, bluntly, by trac-
tion, or by cautious incisions with the
scissors. Any hemorrhage from the
liver substance is arrested either by
pressure or with the thermo-cautery.
5 . Cutting off the bladder between
the two ligatures in the cystic duct.
The remaining stump is folded to-
gether, and securely sutured.
6. Thereupon the abdominal
wound is closed completely.
If the common duct is obstructed
by impaction of calculi, by cicatricial
bands and adhesions to the surrounding parts, by the pressure of the largely
distended gall bladder (on account of its contents), or by tumors of the
neighboring parts {acute and chronic common duct obstruction), the sur-
geon must endeavor to reestablish the escape of bile into the intestine,
in order to remove the danger of choleemia. If it is a question of an im-
pacted gall stone, the operator may try to render it movable by pressure
with the fingers, or to crush it gently with forceps ā the blades of which
are covered with rubber tubing (choledocho-lithotripsy) ā from the outside
through the walls of the choledoch duct.
Fig. 1361. Anatomy of Lower Surface of
THE Liver (according to Henle). L.hd. hepato-
gastric ligament (divided longitudinally) ; D.h.
hepatic duct; /).<:. cystic duct ; Z).f/^. common
bile duct; A.h. hepatic artery; V.p. portal
vein
This should be done very care-
OPERATIONS ON THE ABDOMEN 737
fully, without injuring the internal wall of the canal, already in a state of
inflammation.
If this does not prove successful, it is better to open the wall of the gall
duct over the stone by a longitudinal incision. The escaping bile is care-
fully absorbed with sponges or gauze ; and after the removal of the obstruc-
tion, the wound is closed again by 3-5 silk sutures (choledocho-lithectomy).
The operator should never omit probing the gall duct upward and down-
ward. A thick drainage tube is finally introduced as far as the place of
suture. If the obstacle cannot be removed (extensive tumors and adhe-
sions), an escape for the bile outward may be best established by cholecys-
tostomy, and again administered to the patient with the food ; else, after
ligation of the common duct, a fistula betiveen the gall bladder and tJie small
intestine may be made by broadly suturing the gall bladder to the duodenum
or the small intestine below, in a similar manner as described in gastro-
enterostomy and in enteroanastomosis (cholecysto-enterostomy). This opera-
tion was first made by von Winiwarter ā "a triumph of surgical technique
and perseverance" ā and, after him, by Kappeler and others. Mnrphys
button has also been employed successfully in this operation. (It has
proved to be of special signal success in this operation.)
3 B
OPERATIONS OiN THE SPLEEN
SPLENECTOMY
Excision of the spleen is justifiable in a complete prolapse, cysts and
minors of the same, in abscesses, in floating spleen only when the incon-
veniences caused by the same are very great and cannot be overcome by
the wearing of well-fitting bandages. On the other hand, the extirpation of
the spleen should not be made in tumors caused by serious changes in the
blood {leuccemia, vialajia, amyloid degeneration, etc.).
The difficulty of extirpation consists especially in the separation of the
most extensive adhesions to the surrounding parts and the safe ligation of
the pedicle.
1. The abdominal incision of the greatest service is in the linea alba and
varies in length according to the size of the spleen to be removed. Some-
times a transverse incision must be added to it.
2. After the peritoneal cavity has been opened, the hand is introduced
into the abdominal cavity ; and the surgeon ascertains by direct palpation
the existence of adhesions of the spleen, especially with the diaphragm.
If he becomes convinced from this examination that very extensive
adhesions may frustrate the success of the operation, it is advisable to
abandon the extirpation and to close the abdominal wound.
3. If the operation is decided upon, the adhesions, especially of the
spleno-phrenie ligament, are then detached. This is done with the knife
after double ligation of isolated portions of the bands ; mostly, however, on
account of broad surface adhesions, this method cannot be employed, and
the separation must then be made with the thermo-cautery. Care should
be taken under all circumstances that the capsule of the spleen is protected,
as otherwise profuse parenchymatous hemorrhage may ensue. If any por-
tion of its surface is adherent to any part of the neighboring organs
(pancreas), it is preferable to remove a piece from the latter.
Adhesions to the omentum maybe divided subsequently, ā when the
spleen, after a previous double ligation, has been detached on all sides, and
can be rolled out of the abdominal wound.
738
OPERATIONS ON THE SPLEEN
739
4. Next follows the ligation of the pedicle of the gastrosplenic ligament, in
which tJie splenic artery and vein take their course. If this pedicle is short,
the greatest difficulties may arise in ligating it, and a portion of the spleen
adhering to the pedicle must be left attached to the stump.
For hgation, a strong silk thread or rubber band {OlsJiaiisen) can be
especially recommended, in which case, two additional simple knots are
placed upon a surgeon's knot ; the ends, if necessary, are brought around
the pedicle once more, and tied on the other side.
After division of the pedicle a finger's breadth in front of the ligature,
the lumina of the several blood vessels are sought for in the surface of the
incision, and are tied separately.
5. The stump of the pedicle is returned into the abdominal cavity or
fastened in the wound, for the purpose of facilitating the arrest of bleeding
in the event of secondary hemorrhage {Pe'an); the remaining portion of the
wound is sutured.
If the spleen removed is very large, after the removal of which a dead
space remains in the abdominal cavity, tamponade (according to Miculics ā
see page 675) of the cavity produced is especially to be recommended on
account of the danger of secondary hemorrhage from the separated adhesions
(yLedderhose).
Under some circumstances ā for instance, in cysts or a partial crushing
ā only a portion of the spleen should be removed (resection); the hemor-
rhage from the surface of the incision is arrested by tamponade, by indirect
Hgature, or with the thermo-cautery ; also, by elastic constriction with a
rubber tube, portions of the spleen can be ligated {Liicke).
Splenoplexy ā that is, the stitching of a floating spleen ā in most cases
proves unsatisfactory. The spleen, however, has been elevated and immo-
bihzed by inserting it into a pouch cut into the parietal peritoneum and open
in an upward direction (Rydygier), and by stitching it extraperitoneally under
the costal arch {Bardenheiier).
OPERATIONS ON THE KIDNEY
NEPHROTOMY
Incision of the kidney or its pelvis {pyelotomy) may become necessary: ā
{a) In foreign bodies and calculi, and in anuria and colic caused thereby.
(b) In abscesses, echinococci, and single cysts.
{c) In hydronephrosis and pyonephrosis.
NEPHRECTOMY
{Simon, 1869)
Extirpation of one kidney is made, if the other kidttey is perfectly sound,
and if no ''horseshoe kidney'' exists: ā
{a) In injuries (with violent continuous hemorrhages) of the kidney or
the ureter.
{b) In suppiirative affections (pyelitis and pyelonephrosis calculosa and
tuberculosa).
{c) In incurable ureteric fistulas.
{d) In malignant neoplasms.
(e) In migrating or movable kidney, but only if, after an unsuccessful
nephrorrhaphy, the kidney causes serious symptoms, and is degenerated.
Of the presence of the other kidney the surgeon assures himself by bimanual
palpation, either in the dorsal position with the thighs and legs flexed, or
better, in the lateral position, with the side to be examined upward, whereby
the hip and the knees are slightly flexed. Simon palpated the kidney by
rectal palpation. It is safer, however, to palpate the kidney by direct expos-
ure from the abdomen or extraperitoneally {Foiger) in the lumbar region.
KocJier introduces the hand into the abdominal cavity from the transverse
incision made for extirpating the kidney, and palpates the other kidney
( Thornton).
Of the normal condition of the opposite kidney, the surgeon can convince
himself by obtaining the urine from each kidney separately, for examination,
by catheterizing the ureter. This is accomplished most easily by the use
of the cystoscope ; the older procedures ā compressing one ureter or ligating
it temporarily ā have in most cases been rendered obsolete.
740
OPERATIONS ON THE KIDNEY
741
To expose the kidney extraperitoneally, various methods of incision have
been devised, of which the following are the most important : ā
I. Simon s posterior vd'tical hLvibar incision {Y\g. 1364) along the exter-
nal margin of the erector spinae muscle begins across the nth rib, extends
over the 12th rib, and ends in the median Hne between the 12th rib and the
crest of the ilium (exposes the hilum of the kidney most advantageously).
Fig. 1362. Transverse Lumbar
Incision
Nephrotomy
Fig. 1363. Lateral Lumbar Incisions
I, von Bergmann's; 2, Konig's
2. TJie transverse Inmbar incision according to Czerny, Braiin, KocJier,
Kiister, extends i centimeter below the last rib and parallel to the same from
the margin of the erector spinse
about 8 to lO centimeters forward
as far as the axillary line (colon !
peritoneum!) (Fig. 1362).
3. Vojt Bergniann s lateral
lumbar or obliqne Invibar incision
extends from the anterior end of
the 1 2th rib, descending obliquely
forward and downward as far as ^^^^ ^364. Simon's Position for exiosing Kidney
the junction of the external and
middle third of Poupart's ligament (this incision affords the largest space)
(Fig. 1363, I).
742
SURGICAL TECHNIC
4. Bardcn/icuej-'s renal incision extends from the end of the nth rib
downward to the middle of the crest of the ihum. At its extremities, along
the ribs and the crest of the ilium, transverse incisions are added (trap-door
incision).
Kbnigs retroperitoneal laparotomy incision extends from the 12th rib
vertically along the margin of the sacrolumbar muscle toward the crest of
the ihum, then in the form of a curve toward the umbilicus to the external
border of the rectus muscle.
The patient lies during the operation with his healthy side over a large
circular cushion, so that the lumbar region on the side to be operated upon
becomes prominent and is made
tense (Fig. 1364). With his fist,
an assistant may push the kidney
in a backward and upward direc-
tion by making well-directed pres-
sure from the abdomen. Lange
places the patient in the ventral
position, inclined toward the dis-
eased side, which is made to
project by a pillow placed under
the body opposite the kidneys
(Fig. 1365).
For most cases, as a normal procedure, Simon's method is to be
recommended : ā
1. External incision, see page 741. Having divided the superficial fascia
and the lower margin of the latissimus dorsi muscle, the tough superficial
fascia sheath of the sacrolumbalis {lumbodorsal fascia, lamina sjtperficialis)
is incised ; the rounded margin of this muscle is exposed and the incision
deepened until the 12th rib appears to view in the upper angle of the wound;
the lamina profunda of the lumbodorsal fascia is then reached ; the same is
incised ; after ligation of the XII intercostal artery and the I lumbar artery
crossing the wound, the operator reaches the qnadratiis Inmborum inserted
into the lower margin of the 12th rib. (Since, according to Pansch, there
are cases in which the pleura extends as far as the level of the transverse
process of the first lumbar vertebra, the incision through the deep layer of
the fascia must be made only as far as 2-3 centimeters from the lower margin
of the 1 2th rib.)
2. Division of the gnadratus Inniboriim in a longitudinal direction ; the
divided margins are drawn apart with blunt retractors ; the entire muscle
Fig. 1365. Lange's Position for exposing
Kidney
OPERATIONS ON THE KIDNEY
743
can also be drawn laterally ; under this lies the tough fibrous layer of the
peritoneum, which divides the
anterior surface of the muscle
from the kidney. Having incised
this fascia, the lower pole of
the kidney appears embedded in
loose fatty connective tissue (adi-
pose capsule of kidney).
3. Exposure of the kidney.
First, the superior half, situated
under the ribs, is bluntly sepa-
rated from its surrounding tissues
with the forefinger; next, the
kidney is grasped with three fin-
gers, somewhat drawn forward,
and slozvly and carefully enucle- ā¢^^^- ^366
ated with the forefinger ; only
the firmer adhesions at both poles
are divided with knife or scissors.
If the operation is performed for
injury, the wound can be sutured and the hemorrhage arrested.
If it is done for the removal of cal-
T0POGR.A.PHY OF Renal Region. Mc, m.
cucullaris; ]\Ild, latissimus dorsi; Sp, m. sacrospina-
lis (sacrolumbalis) ; Ql, m. quadratus lumborum;
Oe, m. obliquus ext. abd.; Oi, m. obliquus int. abd.;
Ti-, m. transversus abd.; Fid, fascia lumbodorsalis;
R, kidney; C, colon desc.
1 2 S^
10m
Fig. 1367. Horizontal Section thk* <vGn Lkft
Renal Region, i, m. obliquus ext.; 2, m.
obliquus int.; 3, m. transversus; 4, fascia trans-
versa; 5, fascia lumbodorsalis; 6, its posterior
layer; 7, its anterior layer; 8, m. sacrospina-
lis; 9, m. quadratus lumborum; 10, m. psoas;
II, colon descend,; 12, pancreas; 13, kidney;
14, spleen
culi, after a previous exploration with
needles (akidopeirastic), the kidney is
divided longitudinally on its convex
side by a sufficient incision (as in post
mortems), and the calculi are ex-
tracted with forceps, spoons, or wire
loops (Lauo-e) from the renal pelvis
or the calyces (nephrolithotomy). If
the kidney is healthy and the ureter
permeable, the visceral wound is then
closed by several sutures piercing the
kidney tissue. If the incision has
been made through the renal pelvis,
the wound is reunited by sutures
which invert the margins of the
wound. But if suppuration is pres-
ent, or if the kidney is not entirely
744 SURGICAL TECHNIC
healthy, it is better to drain and tampon the wound of the soft parts sutured
only at its ends. Smaller, well-defined tumors of the cortex can be excised
in the form of a wedge ; the margins of the wound are sutured (renal resec-
tion). If nephrectomy must be made, the kidney is enucleated still farther,
and the adipose capsule is carefully stripped off from its pedicle, until the
blood vessels and the ureter can be distinguished. (The ureter lies nearest
to the back ; behind it lies the artery ; and deepest of all, the vein.)
4. Ligation of the pedicle. First, all the parts entering the hilum are
ligated {ligature ''en masse''); next, the kidney is cut off a little in front of
the ligature, and all visible lumina are singly ligated. The exposed ureter
is ligated after previous invagination.
5. The wound of the soft parts can be closed completely by buried
sutures, or drained and only partly sutured. It is safer, however, first to
tampon everything ; and, perhaps, subsequently to apply the secondary
suture or to allow the wound to heal by granulation.
If, on account of greater accessibility (in large tumors), the operator
desires to employ one of the lateral lumbar incisions, then the operation is
made in a somewhat different manner.
1. External incision according to von Berguiann (Fig. 1363, i).
2. Careful division of the external oblique muscle in the entire length of
the wound, then of the internal oblique in the upper portion of the wound,
and of the transversalis lying beneath it, until the yellowish transversalis
fascia appears to view ; under it lies a layer of loose largely adipose con-