In abdominal surgery, however, the operator should be specially trained for the work. Except in cases of emergency, he should not perform these operations unless he expects to do so continuously. He should be trained by work upon the cadaver and the lower animals and by watching and assisting experienced operators. He should be prepared to deal, without hesitation, with every pathological condition that may be met with in the abdomen; a glance at works on abdominal surgery will show how numerous such conditions are.
A few successes in simple cases in the hands of an incompetent operator will lure him on with false confidence until he finally meets a condition with which he is unable to cope. Either the patient dies as a result, or, if the operator be conservative, the abdomen is closed over an incomplete operation.
The directions which are about to be given apply especially to those operations in which the peritoneal cavity is entered. They may be modified in obvious particulars in case a minor operation is to be performed upon the vagina or the uterus. In such cases special abdominal cleansing is unnecessary and complete evacuation of the intestinal tract is not so important.
The technique described is that which is followed by the writer. Various equally good modifications are employed by other operators. It seems best, however, to give but one rigid method which experience has proved successful. The experienced operator is able to change it according to his individual preferences.
Operating-room.—The operating-room should be well lighted from the top and at least one side. If a good natural light cannot be secured, an electric drop-light will be found very convenient. For work deep in the pelvis or the abdomen a good light is essential. If necessary, light may be directed to the desired point by means of the ordinary head-mirror.
The floor, walls, and ceiling of the room should be of some non-absorbing material. There should be in the room no appliances whatever that are not essential for the performance of the operation.
The interior of the room should be wiped throughout with a mop or with wet cloths, or, still better, flushed with the hose, in order to remove and lay all dust. The room may be wiped throughout with a solution of bichlorid of mercury (1:2000). At the Gynecean Hospital the operating-rooms are disinfected once a week with formaldehyd gas.
The temperature of the room should be not less than 75° F. Shock from bodily loss of heat and exposure of the peritoneum is diminished if the atmosphere of the room is at an elevated temperature.
Apparatus.—All apparatus, such as basins, tables, etc., should be of such a character that it may be sterilized by boiling or by washing with a solution of bichloride of mercury (1:1000). Glass-top tables with painted or nickel-plated frames are preferable. The operating-table should be so arranged that the patient may be placed in the Trendelenburg position ([Fig. 193]). This position permits the intestines to gravitate out of the pelvis, and is very useful in many operations. There are a great variety of tables in use. Before the Trendelenburg posture was introduced the writer used for several years a plain hard-wood plank supported by two wooden horses. The Boldt table is very convenient. With it there is no necessity for a rubber pad for catching fluids. It is applicable for all gynecological operations. Some operators are in the habit of dressing the operating table by placing on it a blanket and sheet. This is unnecessary, unless the patient is in such a condition of collapse that it is essential to preserve all bodily heat. The blanket usually becomes saturated with fluids and serves no good purpose.
The number and arrangement of the basins, tables, stands, etc. used in an abdominal operation are shown in [Fig. 194].