The principles and practice of modern surgery

by Roswell Park

Different schemes for application of the ligature according to the necessities of the case. (Erichsen.)

2. Open division was first suggested in the fourth century by Antyllus. It soon fell into disuse and was taken up during the middle of the past century by Syme, to whom the operation has been frequently credited, although it was really the revival of an antique method; but Syme gave it so much of his anatomical exactness and brilliancy of operative skill that he almost made it his own. The method was essentially one by long and free incision, through which the interior of the sac was fully exposed, its contained clots turned out, its vascular openings plugged, while a ligature was applied above and below in order to prevent further arterial communication. Performed before the days of anesthesia or of antisepsis it was an exceedingly bold procedure, yet in Syme’s hands it gave brilliant results.

3. The open division has been replaced by the more perfect procedure of extirpation of the sac, based upon the general principle that an aneurysm is a tumor and should be extirpated, the parts being sutured and expected to heal promptly. It constitutes in many cases the ideal method of treatment. There could be but one improvement on it, namely, that suggested by Matas, of arteriorrhaphy, as one of the radical methods which is often applicable to aneurysms of the extremities, or to those where rupture has occurred or is imminent. The part should be made bloodless, as in this way perfect control can be secured; should this be impracticable, the vessel should be ligated above the aneurysm before proceeding to its excision. This done, and the vessels secured above and below, the wound may be closed as after any other operation, and in this way radical cure achieved within a few days.

[Fig. 160] illustrates a recent case of this kind in the author’s hands, where an aneurysm of the common carotid, of about the size of a lemon, was treated in this way, the patient leaving the hospital in eight days, and having no unpleasant complications.

Fig. 160

Aneurysm of the common carotid successfully treated by complete extirpation. (Park.)

4. Open division with arteriorrhaphy has been proposed by Matas and Murphy and in their hands has been successful. Its greatest usefulness is found in traumatic aneurysms of long standing where the arterial opening is usually small and the vessel wall healthy, so that after excision of the sac a sufficient amount of aneurysmal wall or stump may be retained in order to afford a firm surface for union. The circulation being controlled the sac is exposed, opened, and dissected down to a location near the arterial opening. Here the arterial walls are trimmed and freshened, turned in or rolled in, and a row of sutures applied, one line apart, through the outer and middle coats. Matas suggests that after the suture is complete the size of the vessel should be less than its normal, in order that pressure may be reduced at this point and more perfect union follow. The method may also be resorted to in certain fusiform aneurysms, where the arterial wall is still sufficiently healthy to sustain sutures. Here an elliptical piece can be excised, or it may be possible to infold the coats of the sac and apply sutures through a series of folds, on the same principle that they are applied in cases of dilatation of the stomach. Arterial suture as practised in these cases is similar to the Lembert suture used in intestinal surgery. It is necessary to support the tissues around the sutured artery by other buried sutures in such a manner as to fortify them against yielding of the arterial coats.

For these radical methods, either by excision or this combined with suture, the arteriovenous aneurysms afford an inviting class of cases. The parts having been made bloodless and the vessels separated, sutures may be applied, if there be sufficient room for them without too much occlusion of the vessels, which would afford but little advantage over ligatures.

In spite of what has been said about the rarity of these lesions, which is true in civil life, it has been shown, during recent wars, that bullets of small caliber having high velocity have produced instances of this character.