A Text-book of Diseases of Women

by Charles B. Penrose

The chief of these regions is the hollow of the sacrum, or Douglas’s pouch. Fluids also collect on the anterior surface of the broad ligaments and in the renal hollows.

If but little fluid has escaped into the abdomen, and the field of operation has been confined to the pelvis, we need look for accumulations of fluid and blood only in Douglas’s pouch and in front of the broad ligaments. If the upper portion of the abdomen has been invaded, it is advisable to inspect the renal hollows. Blood-clot and fluid may be readily removed by the sponge held in the fingers or in forceps.

Irrigation of the peritoneum is not often required. It is not necessary to flood the peritoneum with water in order to wash out blood-clot, which may be removed with more accuracy by sponging. There is always danger, in general irrigation of the peritoneum, of spreading infection.

Local washing of the pelvis is sometimes advisable if the operator fears that the field of operation has been infected by the escape of septic material. Such a condition may exist in operations for tubal or ovarian abscess. The upper peritoneum should be first shut off from the pelvic cavity with a wall of gauze sponges. This may be readily done while the patient is in the Trendelenburg position. She should then be placed in the horizontal position, while the operator, with the left hand pressed against the wall of pads, prevents the intestines entering the pelvis. The abdominal incision should be held open with retractors, and the sterile irrigating fluid should be poured in from a flask or a pitcher. The temperature of the fluid should be 100°-115° F. The fluid may be removed by sponging, and washing may be repeated as often as necessary.

In septic cases the writer has frequently performed such local washing with a bichloride solution (1:2000 or 1:4000), followed by irrigation with plain water.

If the patient is horizontal and the gauze pads be properly placed, there is no danger of any of the fluid entering the upper peritoneal cavity.

Fig. 205.—The mass-suture for closing the abdominal incision: S, skin; F, fascia; M, muscle; P, peritoneum.

Closing the Abdominal Incision.—A variety of methods have been introduced for closing the abdominal incision. The simplest method, that is applicable to all cases, is the interrupted mass-suture, or the “through-and-through” suture. This suture passes through all the structures of the abdominal wall ([Fig. 205]). Some operators advise passing the suture to, but not through, the peritoneum. The writer includes the edge of the peritoneum in the suture. These sutures should be placed two or three to the inch, according to the thickness of the abdominal wall.

Care should be taken to include all the structures in the embrace of the suture. A carelessly applied suture sometimes fails to include the retracted fascia and muscle. The needle should first be directed outward and then inward as it passes through the abdominal wall. It should not pass directly through, parallel to the sagittal plane of the incision. Thus when the suture is tied it forms approximately a circle, and the structures included in it are brought into a plane of apposition.