Warren Stone Bickham.

A text-book of operative surgery, covering the surgical anatomy and operative technic involved in the operations of general surgery. Designed for practitioners and students online

. (page 97 of 126)
Online LibraryWarren Stone BickhamA text-book of operative surgery, covering the surgical anatomy and operative technic involved in the operations of general surgery. Designed for practitioners and students → online text (page 97 of 126)
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gion; dilatation of the sphincter just before operation, in the more compli-
cated cases.

Position. — Patient in the lithotomy position, with nates over the end
of the table; surgeon sitting opposite the perineum.

Landmarks. — Anus; rectum; course of fistula and position of openings
determined in advance, if possible.

Operation. — (1) A grooved director is passed through the sinus, from its
skin opening — made to traverse its length and emerge through its internal
opening within the bowel — and the end of the director is then caused to
project through the anus by directing its tip with the left index-finger within
the rectum, while its handle is depressed with the right hand. The external
and internal openings of the fistula are then in plain view — with the grooved
director passing through its entire length. (See Fig. 698, A.) (2) Upon the
grooved director a narrow, pointed knife is passed (or a probe-pointed bis-
toury may be used) with its cutting-edge directed outward — thus incising
the fistula throughout its entire course — freeing the grooved director and
allowing the parts to recede into their normal positions. (3) The lips of
the wound and of the sinus are then separated by the operator's left thumb
and index — and, while thus exposed, the entire extent of the fistula should
be scraped with a curette, so as to remove its old wall — and then Lightly
packed with gauze and allowed to heal from the bottom. A T-bandage

94 8


keeps the dressing in place. The bowels are usually kept constipated for
a few days.

Comment. — (i) Fistuke-in-ano are generally one of three types; — "Com-
plete" — "Incomplete Internal" — "Incomplete External." In addition, fis-
tulas may have several openings; — and they may have irregular forms, as,
for example, the "horseshoe" type. (See Figs. 694 to 697.) (2) If the
grooved director does not pass readily, a probe may first find the way — and
the director passed along this — and the probe then withdrawn. (3) If the
grooved director, or probe, cannot be made to find an internal communication
with the bowel, but nevertheless comes very near the mucous membrane,
it may be forced the remaining distance, provided this distance be short.
(4) If the end of the director cannot be brought out through the anus, a
narrow, probe-pointed bistoury may be passed along it and the director

Figs. 694—697. — Forms of Fistul^e-in-ano : — A, Rectum in vertical section; a, Incomplete external
fistula ; 6, Incomplete internal fistula ; c, Complete fistula ; d. Irregular complete fistula. B, Surface
view of fistulous tracts, showing various irregular forms of fistula; and diverticula — their external
openings being marked by a star.

withdrawn — and then the end of the probe-pointed bistoury is pressed against
the surgeon's left index-finger (or a special piece of wood) introduced within
the rectum — and finger and knife simultaneously withdrawn — the knife cutting
the intervening soft parts through in its withdrawal. Or one blade of a
pair of scissors may be passed along the director and the sinus thus laid open.
(5) In incomplete internal fistula 1 , the internal opening is found through a
speculum — a bent probe passed along the sinus — and an external opening
made where thus indicated — after which the operation is completed as in a
complete fistula. (6) In incomplete external fistula, if the inner end be very
near the mucous membrane, a director is protruded through the sinus into
the bowel, forcing its way through the thin barrier — after which the operation
is completed as in the complete fistula. If, on the other hand, the inner



opening be not connected with or near the bowel, the entire tract must be
laid open from without. (7) If the fistula extend high up along the bowel,
judgment must be exercised as to what extent cutting is necessary, and to
what extent dilatation and scraping will suffice. (8) In "horseshoe" fistuke
(an external opening on each side of the anus leading to a single internal
opening, generally upon the posterior rectal wall) the bowel function is less

Fig. 698.— Operation for Cure of Fistula-in-ano by Incision and Excision: — A, Bistoury
in act of dividing fistula upon grooved director; B, Fistulous tract being excised by curved scissors,
while steadied with forceps ; C, Suturing of bed of sinus alter its excision ; D, Ligature attached to
gauze tampon in rectum, t<> control contents.

apt to be interfered with if the sphincter be cut on one side only (and at
right angles to the anal orifice) and the opposite part of the fistula be dilated,
scraped, and drained from the first side. (9) Search should always be made
for secondary fistula? running off from the main one, and these likewise laid
open and curetted — or dilated and scraped. (10) The internal sphincter
should not be divided if it can be helped. If it be necessary to incise the


internal sphincter, the division should be at right angles to its fibers at the
site of section (that repair may be more complete, and subsequent functioning).
And it is preferable not to divide the internal sphincter in more than one
place at a time (for the same reasons), (n) Whatever hemorrhage occurs,
which is generally slight, is ordinarily controlled by gauze packing — but gut-
ligaturing may be used where necessary. (12) In appropriate cases the entire
fistulous tract may be dissected out — and the raw edges thus left be brought
together by superficial and deep chromic gut sutures — thus at once obliterating
the site of sinus and inviting primary union. This method is preferable to
simple incision wherever applicable. (See Fig. 698, B and C.)



Description. — Lies in epigastric and left hypochondriac regions — being
about five-sixths to left and one-sixth to right of median line; — lying under
the liver and diaphragm, — above the jejunum, ileum, and transverse colon
(also upon the transverse mesocolon, which intervenes between it and pan-
creas, abdominal vessels and solar plexus), — and between gall-bladder on
right and spleen on left.

Relations. — Anteriorly and superiorly: diaphragm; thoracic wall (an-
terior portions seventh, eighth, and ninth ribs); left and quadrate lobes of
liver; anterior abdominal wall; lesser omentum. Posteriorly and infe-
riorly : diaphragm; crura of diaphragm; aorta and inferior vena cava;
first lumbar vertebra; cceliac axis; lesser peritoneal sac; splenic flexure of
colon ; transverse colon ; transverse mesocolon (superior layer) ; spleen (gastric
surface); left kidney and suprarenal capsule; pancreas; splenic vessels; duo-
denum (fourth, or ascending portion) ; solar plexus. Right end : transverse
colon; inferior surface of liver. Left end : spleen; diaphragm.

Position of Cardiac End (Fundus). — Reaches up to the left sixth chon-
dro-sternal articulation, or fifth rib in mammary line, and to cupola of dia-
phragm; — slightly above and behind the heart apex; — and 3 to 5 cm. (ij
to 2 inches) higher than the cardiac orifice of the stomach.

Position of Cardiac Orifice. — Opposite left seventh chondro-sternal
articulation, about 2.5 cm. (1 inch) from sternum; — also on level with ninth
dorsal spine (left side of eleventh dorsal vertebra). Lies from 2 to 3 cm.
(f to 1 j inches) below the esophageal opening, and about 7.5 cm. (3 inches)
from the left extremity of the stomach, — and n cm. (4 J inches) from the
anterior abdominal wall.

Position of Pylorus. — On level with bony ends of seventh ribs (which
are 5 to 7.5 cm., or 2 to 3 inches, below the sterno-xiphoid joint), lying to
right of median line and nearer the surface than the cardiac end; — also on
level with twelfth dorsal spine (upper border of first lumbar vertebra).

Fixation Points and Ligaments of Stomach. — Bound to diaphragm by
esophagus; — bound to vertebral column by duodenum ; — ligamentum phrenico-
gastricum connects cardia to diaphragm; — gastro-hepatic omentum (lesser
omentum) connects lesser curvature to liver; — ligamentum hepato-duodenale
connects pylorus and duodenum to liver; — gastro-splenic omentum binds
greater end of stomach to spleen; — great omentum binds the stomach only
when itself is bound.


Peritoneal Coverings. — Everywhere — except along the upper and lower
curvatures, and upon the triangular areas at either end.

Arteries. — Gastric; pyloric and right gastro-epiploic branches of hepatic;
left gastro-epiploic and vasa brevia of splenic.

Veins. — Coronary and pyloric, emptying into portal vein; right gastro-
epiploic, emptying into superior mesenteric; left gastro-epiploic, emptying
into splenic.

Nerves. — Right vagus (posterior surface) ; left vagus (anterior surface) ;
solar plexus of sympathetic system.

Lymphatic Glands.— Along greater and lesser curvatures — and at
pyloric and cardiac ends.


Stomach when empty — lies far back in the abdominal cavity, beneath
left lobe of liver and in front of pancreas.

In moderate distention — Cardiac end lies beneath left seventh chondro-
sternal articulation, about 2.5 cm. (1 inch) beyond the sternum. Pyloric
end lies opposite a point near end of eighth right chondro-costal articulation.

Borders (curvatures) of stomach are represented approximately by curves
of the characteristic contour between the points just given — the greater
curvature reaching at first to the left, then downward to the infracostal line.
The lesser curvature crosses the vertebral column on a level with the first
lumbar vertebra. The greater curvature crosses the epigastrium on a line
connecting the ninth and tenth costal cartilages — which is about two finger-
breadths above the umbilicus.

Gastric fossa — a triangular area of about 40 square centimeters (15J
inches) of the anterior wall of the stomach where it lies in direct contact
with the abdominal wall — bounded, below, by the transverse colon; above
and to left, by seventh, eighth, and ninth costal cartilages; and above and
to right, by the anterior border of the liver.


Stomach may be recognized by its relation to the inferior surface of the
liver — by its continuity with the anterior layer of the gastro-hepatic omentum —
L7 its thick and stiff wall, as detenrJned by pinching it up between the fingers —
by the direction of its vessels — and by its pinkish-w?.- ;e color and absolute
opacity. The stomach and transverse colon have been mistaken for each
other. The transverse colon should be displaced downward and the liver
upward — revealing the stomach between them. If not otherwise recognizable,
follow back the under surface of the liver to the portal fissure, with the index-
finger — thence downward along the gastro-hepatic omentum to the stomach.

Anterior gastric wall lies in the greater peritoneal cavity — and its posterior
wall in the lesser cavity.

Superior wall of the transverse colon lies in the lesser peritoneal cavity — ■
and its inferior wall in the greater cavity.

Mesentery descends downward and forward from under the back part
of the transverse mesocolon. The omentum major descends from the greater
curvature of the stomach and inferior aspect of the transverse colon — and
mav contain a cavity and be continuous with the omentum minor above
the transverse colon — but its component layers are more generally united.
The omentum can be more conveniently displaced upward and to the left.


Note. — Other general surgical considerations will be mentioned under
special classes of gastric operations.


Scalpels; straight and blunt-pointed bistouries; scissors, curved and
straight; dissecting and toothed forceps; tenacula; artery-clamp forceps;
various retractors; large gauze pads; broad spatula?; intestinal clamps; stomach
clamps; Murphy button; sponge-holders; volsella; stomach-tube; rubber
tubing (for gastrostomies); needles, curved and straight; needle-holders;
sutures, silk and gut; ligatures, silk and gut; ligature-carrier, wound-hooks.


Description. — The passage of a hollow tube down the esophagus and
into the stomach — for the purpose of removing fluid from, or injecting fluid
into, the stomach.

Position. — Patient sits upright in chair or in bed — head thrown backward
(preferably steadied by an assistant) — mouth gagged (preferably, but not
necessarily) — napkin placed over tongue to enable it to be more easily grasped;
— Surgeon stands in front.

Operation. — The surgeon depresses the base of the tongue with the left
index-finger, and, at the same time, draws it forward — this finger thus also
guarding the larynx. The tube, previously warmed and lubricated, and
held in the fingers of the right hand, is guided along until it impinges upon
the posterior wall of the pharynx, when it is directed downward. The esopha-
gus once entered, the tube is gently pressed further downward, aided by
the act of swallowing, until it has entered the stomach.

Comment. — In the average adult, the distance from the upper incisor
teeth to the superior end of the esophagus is given as 14 cm. (5J inches); —
from the same point to the arch of the aorta, as 23 cm. (9 inches) ; — and from
the same point to the diaphragmatic opening, as 37 cm. (14 J inches). Pouches
and diverticula of the esophagus are to be avoided.



Description. — Consists in the temporary opening of the stomach by
incision, followed by its closure at the same operation. Generally resorted
to for removal of foreign bodies, for exploration, or for treatment of surgical
conditions of the stomach, pylorus, or esophagus (such as gastric ulcer,
dilatation of the esophageal or pyloric orifice, dilatation of the esophagus,
etc.). The opening may be made in the median line, or below and parallel
with the left costal arch. As far as possible, transverse division of muscles
and injury to nerves should be avoided.

Preparation. — Stomach washed out.

Position. — Patient supine; Surgeon to patient's right, cutting from above
downward; Assistant opposite.

Landmarks. — Linea alba; xiphoid cartilage; umbilicus.

Incision. — In the median line — its center being about opposite the space
between the eighth and ninth costal cartilages — and extending to or toward
the tip of the xiphoid cartilage above, and to or toward the umbilicus below,
as far as the circumstances of the case require — generally being from 5 to 10
cm. (2 to 4 inches) long. (Fig. 699, A.)



Operation. — (i) The steps of the operation, up to entering the peri-
toneal cavity, are exactly similar to those for median abdominal section (see
page 631). (2) The edges of the abdominal wound are now well retracted
and the stomach sought — the steps for its recognition being given under Gen-
eral Surgical Considerations. While searching for the stomach, which is
often not easily located, temporary silk sutures, or traction-ligatures, may be

Fig. 699. — Incisions for Exposing Stomach, Liver, Gall-bladder, and Spleen: — A,
Median, for stomach, liver, or spleen; B, Oblique subcostal, for stomach; C, Vertical over outer
third of left rectus, for stomach; D, Vertical subcostal in left linea semilunaris, for spleen; E,
Oblique subcostal, for spleen; F, Oblique subcostal, for liver and gall-bladder; G, Vertical
subcostal in right linea semilunaris, for liver and gall-bladder. (Diagram modified from Deaver.)

placed through the entire thickness of each abdominal lip — partly to serve
as retractors, and partly to prevent the separation of the peritoneum from
the abdominal wall. (3) Having located the stomach, that portion of its
anterior wall into which the incision is to be made must be isolated and
drawn out of the wound by means of the fingers or special traction-forceps,
the general peritoneal cavity being packed off with gauze. The site of the
opening into the stomach will depend largely upon the site of the foreign
body, or upon the special object of the operation. (4) An assistant grasps
the anterior stomach-wall toward either side of the retracted abdominal
wound, between his thumbs and fingers, steadying and spreading out that
surface — or temporary silk traction-sutures may be passed, with curved


needle, into the stomach-wall, without entering its cavity — thus exposing
an area of about 5 to 7.5 cm. (2 to 3 inches) of the anterior stomach-wall.
(5) This area having been put upon the stretch, an opening of about 3.7 to
5 cm. (i| to 2 inches) is made in the vertical axis of the stomach, parallel
with the blood-vessels — or it may be made parallel with the long axis, avoiding
large vessels. This opening may be made by a quick, controlled stab of a
narrow, sharp bistoury, penetrating all the coats, and then enlarging with
blunt-pointed bistoury — or it can be more deliberately made by a pair of
scissors, picking up a fold of stomach-wall and cutting through at right angles
to the fold. (6) Two temporary traction-sutures are at once placed in the
opposite lips of the stomach wound, to hold them in control, and to enable
the interior of the stomach to be exposed by retraction of its walls. The
stomach opening may be enlarged if necessary. Clamp and twist all bleeding
vessels, carefully isolating and ligating with gut any requiring ligature. If
indicated, the stomach may be washed out, thoroughly protecting the abdom-
inal cavity from soiling. (7) The object of the operation is now accom-
plished. The stomach-wall is then sutured in the manner described under
Gastrorrhaphy, page 955, — with a tier of sutures through the mucous coat,
and an overlying tier of Lemberts through the outer coats — using, preferably,
fine chromic gut. The stomach is then dropped back into place and the
abdomen closed in the usual fashion.

Comment. — Where the cardiac end of the stomach is the special site
sought, it is more conveniently reached by an oblique subcostal incision (q. v.).
The above incision is the best for the pyloric end, and for all other portions
of the stomach except the cardiac end — and for general exploration and most
foreign bodies.



Description. — The stomach is opened by an incision parallel with and
below the left costal arch — which more conveniently exposes the cardiac end
of the stomach and the cardiac orifice of the esophagus.

Preparation — Position. — As for Median Gastrotomy.

Landmarks. — Xiphoid cartilage; left costal arch.

Incision. — Begins near the tip of the xiphoid cartilage and extends
thence downward and outward, parallel with and about 2,5 to 3,7 cm. (1 to
1 J inches) to the inner side of the left costal arch, ending about opposite the
anterior end of the ninth rib, — generally extending for a distance of 5 to 7.5
cm. (2 to 3 inches), varying with the thickness of the abdominal wall and other
circumstances. (Fig. 699, B.)

Operation. — (1) Incise through skin and fascia, clamping all bleeding
vessels. The incision will pass through the fibers of the external oblique at
about a right angle to its fibers, — will pass between the fibers of the internal
oblique, — and will divide those of the transversalis transversely to their
course, — but will pass more or less parallel with the seventh and eighth nerves,
which, if possible, should be recognized and drawn aside. (2) The peri-
toneum is opened in the line of the original incision — the stomach is recog-
nized — isolated — and drawn into the wound, the general peritoneal cavity
being well oacked off — and its anterior wall is opened in the same general
way as described in Median Gastrotomy, and in the special site selected.
(3) The object of the operation having been accomplished, the stomach-wall
and the abdominal wound are closed in the manner just described.



Comment. — (i) The above operation is very similar to that of Gastros-
tomy by the same incision. (2) Large, irregular, impacted bodies are some-
times removed by incisions made directly over them and giving access by the
nearest route.


Description. — Suturing of the stomach-wall. Generally resorted to
for wounds, closure after operations, ulcers, etc. (Sometimes gastrorrhaphy
is unadvisedly used synonymously with gastroplication.)

Preparation — Position — Landmarks — Incision. — As for gastrotomy
bv median incision.

Operation. — (1) The peritoneal cavity having been opened, hemorrhage
controlled, and the wound retracted, the stomach is exposed and brought

Fig. 700.— Gastrorrhaphy : — A, Line of overhand continuous suturing through all coats; B, Inter-
rupted Lemhert sutures through outer coats.

forward. (2) The area being packed off with gauze, the site of the operation
is conveniently held by an assistant. (3) The mucous membrane is first
sutured with continuous sutures of fine silk or gut — by means of a curved
needle held in a holder in the right hand, while picking up the mucous mem-
brane with forceps in the left. (4) A second line of interrupted Lemberl
sutures of fine chromic gut is now applied, passing through the serous and
muscular coats of both lips of the wound, and thus bringing serous surfaces
into contact. (5) The stomach is then returned to its place — and the abdo-
men sutured as usual.

Comment. — (1) Chromic gut may be used throughout. (2) The first


tier of sutures may consist of an overhand stitching through the entire thick-
ness of all the coats, applied continuously — followed by interrupted Lembert
sutures passing through the serous and muscular coats and burying in the
first tier. (Fig. 700.) (3) Sometimes three tiers are applied — a continuous
stitch through the mucous coat — an interrupted or continuous through
the muscular — and an interrupted through the serous. (4) In cases of
suturing for gastric ulcer — (a) the edges (in simple cases) are merely in-
vaginated by sutures, first of the mucous membrane, then of the serous
and muscular coats; — (b) Or the ulcer may be excised (in hard, thick
walls, or in large ulcers) elliptically, the edges of the ellipse being united
by the two tiers just described. (5) All lines of gastric suturing may be rein-
forced bv omental grafts sutured over the suture-line.


Description. — Bv gastrostomy is meant the establishment of a more or
less permanent fistulous opening in some part of the anterior wall of the
stomach, for the purpose of alimentation or surgical treatment — the stomach
generallv being attached by suture to the anterior abdominal wall just pre-
ceding or following the incision of its wall. The operation of Gastrostomy
may be done in one or in two stages. Where haste is a consideration, the
opening must be made into the stomach as soon as the latter is attached to
the abdominal wall. Where haste is unnecessary, the stomach is first attached
to the opening in the anterior abdominal wall — from three to five days given
for union to take place, shutting off the peritoneal cavity — and then the
stomach is opened. In such cases as those in which the operation is done
for inoperable cancer, the gastrostomy is meant to be permanent. Where
the operation is done for temporary cause, the fistula is expected to subse-
quentlv heal of its own accord (which is generally the case), or a special opera-
tion is done later for its closure.

Preparation of Patient. — The stomach is washed out; the site of opera-
tion is shaved; the bowels are emptied.

Position during Operation. — Supine, at the side of table, with abdominal
parietes relaxed by slight elevation of the shoulders and slight flexion of the
hips; Surgeon to right in operating in median line, and to left in the sub-
costal operation; Assistant opposite.

Division of Abdominal Parietes. — Muscles should be divided in their
cleavage line, in so far as this is possible — and the abdominal nerves should
be spared, as far as practicable. A disadvantage of all oblique incisions
parallel with and just below the left costal arch is the difficulty of making

Online LibraryWarren Stone BickhamA text-book of operative surgery, covering the surgical anatomy and operative technic involved in the operations of general surgery. Designed for practitioners and students → online text (page 97 of 126)