On harelip and cleft palate

by William Rose

The Operation.

It will be convenient first to describe in detail the technique of the operation in a typical case of combined cleft of the hard and soft palate, i. e. the operations of uranoplasty and staphyloraphy combined, and subsequently indicate the modifications necessary under special circumstances.

The method which is now almost universally employed is that known as Langenbeck’s, effecting complete closure by dissection of muco-periosteal flaps obtained from either side of the cleft, and sutured in the middle line. Although called after the great German surgeon, and rightly so, inasmuch as he first clearly enunciated the principles underlying the operation, it is certain that similar plans had been previously employed by others. The late Mr. Avery, of Charing Cross Hospital, seems to have been the first in this country to completely close a cleft in the hard palate, and he employed and described[88] a method very similar to Langenbeck’s. This was undertaken in 1848, and in 1853 Messrs. Weiss made improved and special raspatories for the operation. Langenbeck’s paper, on the other hand, did not appear until 1862. Previous to this various plans of surgical treatment had been employed. Operations upon the soft palate were undertaken much earlier than upon the hard, and although priority has been claimed both for Prof. Graefe[89] (1816) and M. Roux[90] (1819), who performed staphyloraphy independently, yet it is certain that a similar proceeding had been adopted by others in the latter half of last century. The first reference to a successful case that we possess is in 1760, when a dentist named Lemonnier[91] united the borders of a cleft in a child. Desault and others record similar cases in the first decade of this century. As regards the hard palate, M. Krimer[92] seems to be the first who attempted operative treatment (1824); he dissected up small muco-periosteal flaps on either side of the cleft, reversed them from without inwards, and united them in the middle line by sutures. M. Beaufils made use of a single flap twisted on itself so as to fill the aperture. Dr. Mason Warren in 1843 published a method of operating which seems in his hands to have been moderately successful, although only after repeated operations. He dissected up the mucous membrane, and freed the soft palate by dividing the posterior pillars with strong curved scissors, and then sutured in the median line. Several methods of “bony suture” have also at different times been suggested. Dieffenbach[93] led the way in 1826, and was followed by many other surgeons, Fergusson and Mason being prominent amongst them in this country. But the results were never satisfactory, and the method has now been entirely superseded by Langenbeck’s operation, which is applicable in almost all cases.

It may be divided into four stages:—

Stage 1. Incision, and detachment of muco-periosteal flaps.

Stage 2. Paring the edges of the cleft.

Stage 3. Passage and tightening of sutures.

Stage 4. Relief of lateral tension.

Stage I.—Incision and Detachment of Muco-periosteal Flaps.

The patient being thoroughly anæsthetised, and the mouth held open by the gag, the surgeon, standing on the right side of the patient, commences by making a lateral incision, preferably on that side of the cleft which is opposite to the gag; it facilitates matters to shift the gag to the opposite side of the mouth when the second incision is made. These incisions should commence a little internal and opposite to the last molar tooth ([Fig. 67 A]), and should be carried forward parallel to the alveolar margin to a point immediately behind the lateral incisor, terminating a little anterior to the apex of the cleft, if the alveolus be intact. The knife should be held so that the incision is always perpendicular to the varying planes of the mucous membrane, in order to prevent the edge from being bevelled, which may seriously impair its nutrition. All the structures should be cleanly divided down to the bone.

Fig. 67a.—Diagram to indicate the extent of the incisions in Langenbeck’s operation. The thick black lines show the primary incision; the thick dotted lines the extension backwards of the same to relieve any lateral tension (made after the insertion of the stitches); the thin dotted lines indicate approximately the position of the free posterior border of the bony palate.

Fig. 67b.—Shows the position of the sutures and the condition of the parts at the close of the operation.

Hæmorrhage, even to a considerable amount, naturally follows, and this should be checked by pressure with purified sponges; it will be much more serious should the palatine arteries be included in the line of incision. The distribution of the anterior and posterior palatine arteries is so variable, and their pulsation so rarely to be felt beforehand, that it is not always possible to avoid wounding one or other of them. Should this occur, it is important that the vessel be completely divided, as a buttonhole in it will cause severe and protracted hæmorrhage. During the bleeding the patient’s head should be turned on one side and lowered, so as to allow the blood to run freely out of the mouth and not into the throat.

Whilst the assistant is staunching the hæmorrhage, the operator can introduce the raspatories through the openings thus made, and working them from without inwards, separate the whole of the muco-periosteal tissue. To effect this, different shapes of instruments will be required in order to follow the curves of the palatal segments, and those devised by Mr. Durham will be found most useful ([Fig. 60]). In loosening the flaps anteriorly, the advantage of the double-curved raspatory ([Fig. 68]) will be obvious. As the point of the raspatory reaches the inner free margin of the palatal segment, the separation of the muco-periosteal flap should be completed by the protrusion of the instrument into the cleft at the junction of the buccal and nasal mucous membranes. This is more readily accomplished if the edges have been previously pared; but it is better to postpone this step until the flaps have been detached, as the raw edges are less liable to be bruised by the sponging, and with the flaps loosened the margin can be pared with greater accuracy. In cases where the vomer is attached to one free edge of the palate ([Fig. 11]) the junction of the nasal and buccal mucous membrane should be incised to prevent its being lacerated by the raspatory.

The attachment of the soft structures to the hamular process and back of the hard palate must be freely and fully divided. This is a most important and delicate part of the operation, and as the structures are here extremely thin, great care must be exercised. Should this separation be incomplete, the lateral incision cannot be carried down into the soft palate, and the flaps will not come into proper apposition. It may be attained by the use of a sharp cutting raspatory kept close to the bone, and as regards the hamular process, by a narrow probe-pointed bistoury, or a pair of curved scissors. The introduction of the left forefinger into the incision is of great assistance in effecting this with precision and thoroughness.

Fig. 68.—Double-curved raspatories for detaching the anterior portion of the muco-periosteal flaps in uranoplasty.

After detachment the muco-periosteal flaps will often appear blanched or of a bluish-white colour as a result of the interference with the circulation, a fact which has been commented on by M. Trélat. The circulation, however, is soon re-established, and the normal colour returns in a few hours.

When this proceeding has been satisfactorily accomplished on both sides, a temporary delay generally occurs for the assistant to arrest the hæmorrhage, and for the anæsthetist to get the patient more fully under control, so that the second most important stage may be conducted without any struggling.

Stage II.—Paring the Edges of the Cleft.

The extreme inner edge of the cleft velum should be seized near the base of the half uvula with the catch forceps ([Fig. 62]). The narrow-bladed knife ([Fig. 61C]) is entered with the back towards the tongue, just in front of the forceps, and made to cut the merest shaving from the margin as far as the apex of the cleft. Before relaxing the grasp of the forceps, the same process is continued backwards to the apex of the half uvula. The other side of the cleft is similarly treated, and, if possible, the strip of marginal tissue removed should be continuous throughout, thus satisfactorily proving that the whole of the cleft has been pared. This strip should be cut square with the palate, for if bevelled, the edges cannot afterwards be brought into such accurate apposition.

Care should be taken in this proceeding not to contravene the important canon of plastic surgery, that no unnecessary amount of tissue should be removed; for it is most important to remember that in these cases, there is no excess of material, and that a too free removal of marginal tissue will lead to increased tension in the united palate, and subsequently to a less satisfactory functional result from defective closure of the posterior nares.

Stage III.—Passage and Tightening of Sutures.

The quickest method and the one calculated to disturb the parts the least is a modification of that introduced and practised by the late Sir William Fergusson, the so-called “loop-method.” It consists in the passage of a loop of fine silk through both sides of the cleft, to act as a carrier for the silver wire which is to be the permanent suture. One of the needles already described, previously threaded with a piece of fine silk about sixteen inches in length, so that its ends are equal, is passed from the buccal aspect through the loose flap close to the margin of the cleft (i. e. about 2 or 3 mm. from it), and as near as possible to its anterior extremity. To accomplish this it is unnecessary to hold the flap with forceps, as its margin may be seriously damaged. The needle track should be perpendicular to the palate surface, and therefore parallel to the pared margin of the cleft. The silk is then seized close to the eye of the needle with the smooth-nosed forceps introduced within the cleft, the needle withdrawn, and the loop pulled forwards sufficiently to be laid temporarily on the side of the cheek. The same process is repeated at an exactly corresponding point on the opposite side, so that now there are two loops emerging from behind forwards through the cleft. By loosely threading the right loop through the left and gently withdrawing the latter, the former is carried through the flap on the left side ([Fig. 69]); in this way we have a double thread, with its loop on the left side and its free ends on the right, passing through the flaps on either side. This process is repeated at intervals of about 5 to 6 mm. throughout the length of the cleft from before backwards, until the uvula is reached, the anæsthetist and assistant guarding the loops and ends of the silk by placing their hands on them at the sides of the face. This is especially needed if much sponging is called for, or if vomiting occur. The uvula need not be dealt with until the silver sutures have been tightened.

Fig. 69.—Loop method of passing sutures in palate operations. (Mason.)

The silver wire must next be substituted for these loops, and this is effected by taking a six-inch length of the former and doubling half an inch of one end into a hook over the loop; gentle traction on the free ends of the silk will easily draw the wire through into its place. A small piece of sponge lightly dabbed on the edges of the cleft at the point of suture removes any adherent blood-clot or mucus. The ends of the wire are crossed and the wire-twister ([Fig. 66]) applied, and in this way the suture is tightened until the margins of the cleft lie accurately in apposition, without undue mutual pressure or folding in of the edges; experience and practice can alone decide the requisite amount of tension. When this has been accomplished, the twisted ends are cut off with scissors, leaving a sufficient length visible to allow of easy removal when necessary. It is better to deal in this way with each wire separately, in order to prevent entanglement or confusion.

To stitch the uvula, a double-curved semicircular needle ([Fig. 63]) may be advantageously employed, and passed through both sides before withdrawing it; as previously stated, no substitution of wire is advisable ([p. 114]), but the silk is drawn tight by means of a slip-knot made fast in the usual way ([Fig. 70]). Two of these silk sutures may often with advantage be inserted in the uvula, but this should be accomplished with the greatest possible delicacy of manipulation, as any rough handling with the forceps may result in bruising, œdema, and subsequent non-union. The sutures, moreover, must be so placed that the circulation in the uvula is not interfered with when they are drawn tight, or strangulation and sloughing may follow.

Fig. 70.—Method of tying slip-knot for uvula stitch; formerly used in each suture. (Fergusson.)

Fig. 71.—T. Smith’s palate needle (Arnold).

Although the above detailed process appears very elaborate, it certainly seems to me the best. Other methods are used by many, and amongst these perhaps the most frequently employed is the “direct” method of Mr. T. Smith. In this the needle ([Fig. 71]) is double-curved and hollow, and the wire which is wound on a drum in the handle of the instrument can be projected at will from the aperture at the point by a movement of the thumb. Different shapes are used for different parts of the palate. The needle is passed from below upwards through one side of the cleft, and without withdrawing it through the other from above downwards; the wire is now protruded from the point of the needle, grasped by forceps, paid out from the drum, and the needle withdrawn as it entered. Mr. Smith’s usual practice is to stitch from the uvula upwards, tying each stitch as it is inserted, and making use of the ends of one stitch to steady the palate whilst introducing the next. The advantage claimed for this method, viz. the saving of time, is more than counterbalanced in my opinion by the following drawbacks; first, the strain exercised upon one of the palatal flaps in order to pass the needle through the other; second, the occasional and not infrequent hindrances to the smooth working of the wire by its kinking; and, thirdly, the difficulty often experienced in seizing the end of the wire.

Stage IV.—Relief of Lateral Tension.

The palate having been thus satisfactorily sutured, the relief of lateral tension and the division of the levator palati have now to be undertaken; for however well the parts may appear to lie, it is never safe to omit this. A narrow-bladed probe-pointed bistoury is introduced through the lateral aperture on either side, and carried directly backwards through the soft palate. It is useful to introduce the left index finger into the lateral opening to ascertain if any fibres of the muscle still remain undivided. This plan was first introduced and practised by Mr. Pollock in mild cases of cleft palate, where the fissure extended through the velum only.

It may not be out of place to notice the method adopted by Sir W. Fergusson for dividing the levator. A triangular-bladed knife set at right angles to a long stem was introduced behind the velum, and the two edges of the angular point made to cut their way between the pterygoid plates down to the bone, so as to divide the muscle close to its origin. From a theoretical point of view this appears all that can be desired; but practically the results following this procedure were not always satisfactory, inasmuch as the tension upon the stitches often appeared to be but little relieved, and one could never tell with certainty whether the muscles were effectually divided or not; in addition to which, unless the surgeon were very skilled in the use of the instrument and the anatomy of the region in which he was cutting, serious mischief might and did sometimes ensue. A knife such as the one to be employed, cutting at right angles to the handle, can never be used with absolute precision, particularly when the part to be dealt with is out of sight. The ease and certainty with which the structures can be divided by the former method of prolonging the lateral incision backwards have rendered this plan of Fergusson’s obsolete, although in his hands it was often very successful.

Should the hæmorrhage from these final incisions made in the soft palate be excessive, steps should be taken to ascertain whether the trunk or any large branch of the posterior palatine artery has been partially divided, as if so the bleeding is liable to recur at intervals, and may become serious. Under such circumstances, complete division of the vessel has almost always the immediate effect of staying the hæmorrhage. Sponge pressure and syringing with iced boracic lotion may be useful adjuncts in arresting the general oozing; but long continuance of the latter is detrimental to the vitality of the flaps and may endanger primary union. For a similar reason, plugging the lateral apertures, or recourse to powerful styptics, such as perchloride of iron, should if possible be scrupulously avoided.

All lateral tension being now relieved, and no serious hæmorrhage continuing, the sutured palate should present a solid, if somewhat blanched appearance in the middle line; the gag can be removed and the operation is complete.

Thus far we have been describing the operative treatment in the severer forms of cleft, in which both hard and soft palate are involved. When, however, the velum alone is cleft, merely the operation of staphyloraphy is required. In such cases the lateral incisions need not be of such an extensive character, and are usually made after the edges have been pared, and the stitches passed. It was for this type of case that Mr. Pollock introduced his method of dividing the levator palati by entering the knife through the mucous membrane of the velum a little in front and to the inner side of the hamular process, which can be felt in the mouth just behind the last molar tooth. The knife is pushed through the substance of the palate, and then by raising the handle and depressing the blade the muscle can be fully divided without making too extensive an incision in front. I should strongly recommend, however, a sufficient incision being made to admit the tip of the index finger, in order to ascertain with certainty that no tense fibres of the muscle remain undivided.

When the uvula alone is cleft no lateral incisions are necessary.

When the cleft extends for a short distance into the hard palate, lateral incisions must be made in the first stage of the operation, extending to a point a little anterior to the apex of the cleft, for the purpose of introducing raspatories to loosen the soft tissues around this point.

In some cases, after the soft palate has been brought together, a certain amount of tension is observed to be exercised upon the flaps by the traction of the muscles in the pillars of the fauces. If this be so, they should be divided by snipping them across with a pair of blunt-pointed scissors curved on the flat. By this means lateral tension is diminished, and the velum can be subsequently more easily approximated to the posterior pharyngeal wall.