The principles and practice of modern surgery

by Roswell Park

GENERAL TECHNIQUE OF ABDOMINAL OPERATIONS.

Abdominal section, generally called laparotomy, though more properly termed celiotomy, is often begun as an exploratory measure, and then called exploratory laparotomy, whose wisdom and safety may be properly explained to even an ignorant patient, the underlying intent being a relatively small and safely made opening for the purpose of orientation and decision. It is with me a rather favorite expression that the danger of such an operation is insignificant, and that the danger of whatever may be required, as revealed through the opening, is proportionate to the gravity of the condition thus indicated.

Abdominal section having once been decided upon, careful general and local preparation should be made, as indicated elsewhere in this book, if time be afforded. There are, however, emergency cases in which moments are valuable and when there must be omitted almost everything but the considerations of cleanliness. More and more I am impressed with the value of sterilization of the entire trunk, both front and rear, since should necessity for posterior drainage be revealed we need not halt in order to disturb everything else and sterilize the skin of the back. It is presupposed, then, in this place that all the ordinary measures have been carried out and that the ordinary equipment is at hand. There should always be a supply of warm, sterile water (112°) in order that the intestines may be protected, should it be necessary to temporarily remove them from the abdominal cavity, and saline solution at proper temperature should be ready for irrigation purposes, if needed.

The abdomen may be opened at any point, and by incision in almost any direction. Nevertheless there are provisions which should be observed. When there is no special reason for a lateral incision it is to be opened in the middle line; any incision, including the umbilical region, should be made to pass to the left of the navel rather than to the right. There is no reason why the entire navel may not be excised. It is a difficult point at which to insert sutures and in most individuals is at best an infected region. Therefore there need be no hesitancy to include it in an oval incision and completely remove it. It is, furthermore, a wise precaution to drop into the umbilical region a few drops of tincture of iodine just before the operation, in order the better to sterilize it. It is my custom to use one knife for the skin and then lay it aside and employ another for the deeper work, in order that no germs may be transplanted from the skin. The surgeon has to cut deeply in fleshy individuals before reaching the deep aponeurosis, and sometimes it is necessary to pass through two or three inches or even more of fat. This necessitates a long, superficial incision. The deep aponeurosis being reached we have to either go through or between muscle fibers, at least in most places. It is desirable rather to separate muscle fibers longitudinally. When opening in the middle, or parallel to the middle line, this may be done with the fibers of the rectus, the transverse tendinous intersections, however, always requiring division. Operating in either iliac fossa, and coming down upon the broad and flat abdominal muscles, there may be adopted the so-called “gridiron method,” and, after exposing those fibers which run at a right angle to the line of incision, one may endeavor to spread rather than divide them. This is done when making the small openings required in removing the appendix, or in making an artificial anus. For removal of considerable tumors, or for temporary disembowelling, large incisions, however, are required.

By suitable disposition of the patient’s body much assistance and comfort are afforded the operator. When the upper abdomen, especially the region of the gall-bladder, is to be attacked, the upper part of the body should be raised with dorsal flexion above the pelvis, thus permitting gravitation away from the liver and facilitating the retraction which may be required. Again, in operations upon the pelvic viscera the reverse position was suggested by Trendelenburg, and it is of the greatest help, the pelvis and the limbs being elevated until the body assumes a position at an angle of some 45 degrees. The intestines then gravitate toward the diaphragm, and the pelvis is more easily emptied and kept empty. When, however, there is no particular need for either of these positions the ordinary dorsal position is the best. With an operation begun in the latter there should be no reason why position may not be changed, when the exploration reveals necessity for the same, and all good modern operating tables are so constructed as to permit of this being rapidly done.

Of late the transverse incision has been received with growing favor. In 1896, Küstner reported a number of cases where he had used a transverse suprapubic incision down to the aponeurosis solely for a cosmetic effect, the method being adopted by Rapin about the same time. Others went farther and made use of an incision above the pubis and parallel to it, carried down through the aponeurosis, over the recti, with vertical separation of the muscles, in order to diminish the chances of hernia. The incision is made just below the margin of the pubic hair or in the natural fold of the abdomen. The fascia being divided in one direction and the muscle in another, there is less tendency to hernial protrusion, the disadvantages being that there is limited space through which to work and that more time is required in its performance. All vessels should be secured so soon as divided. The incision through the fascia may be somewhat curved, if necessary, at the outer edges of the recti, by which a sort of horseshoe flap may be lifted up if desired. The fat should not be dissected from the surface beneath. Scissors will be required to separate the aponeurosis from the muscles in the middle line, this separation being made high in the same line. The peritoneum is opened in the middle with the usual vertical cut. When more room is required the aponeurosis should be incised farther on each side, outside of the recti. The method finds its greatest serviceability in those cases where not more than four inches in a thin woman and two inches in a fat woman of vertical separation of the recti muscles will be required.

Ordinarily when the peritoneum is reached there will be no difficulty in recognizing it. It is a membrane easily shifted, both upon its attached surfaces, beneath the fat, and over the bowel or whatever may cause it to protrude into the wound. Unless one is very sure of his work he will, however, pick it up very carefully, nick it slightly, and convince himself that he has the desired membrane, and then will dissect it with care, since the bowel beneath will lie closely in contact with it, and might easily be wounded were the operator careless. The peritoneum in the presence of such disease as tuberculous peritonitis becomes very much thickened, and is then not easy of recognition. Again, it is sometimes slightly adherent in the presence of recent exudate, or firmly adherent in the presence of old disease, to the tumor or viscera beneath. When the tissues are edematous and become more so as the peritoneum is approached, pus may be found beneath, and extreme caution should be exercised, making at first a small opening through which pus may escape, and endeavoring not to tear adhesions apart nor thus permit escape of pus into the peritoneal cavity.

The true abdominal cavity once opened, the first endeavor should be to ascertain the conditions within. Through a small opening this is done with the finger. This measure, trifling as it seems, requires a knowledge both of normal and pathological anatomy which cannot be too great. Unless the normal arrangement, size, density, and location of all its contents is known and the way which they should feel when healthy it will be somewhat difficult to distinguish between health and disease. Again, unless the surgeon is familiar with pathological conditions he will not know how to interpret what he may thus discover. Through a small opening it can usually be discovered whether or not there is a serious condition within. According to knowledge thus gained there may be justification for enlarging a small opening or closing it. One caution here is of the greatest importance—an exploratory operation should never be begun unless the operator is provided with means for meeting any indication which should thereby be disclosed, else the patient would be subjected to two ordeals when one should suffice.

The “diagnostic finger,” having once entered the abdominal cavity, should be used with extreme gentleness, especially in the presence of adhesions, which yield easily, and which may point to the existence of a purulent focus in the neighborhood, as scarcely any disaster could be more fatal than to rupture such a focus and permit escape of its contents in every direction before surgical protection has been afforded. Much will depend upon whether there is reason to suspect the presence of pus, and it is always best to proceed as though such a contingency might happen. Again, adhesions which seem firm may be met with in the presence of malignant or ulcerative disease. In some instances they will be so firm that surrounding normal structures will yield before they part, or are closely associated with a dense adhesion which will be found a weakened area that will tear easily. The process of separating adhesions, then, should always be conducted with extreme caution.

When the presence of pus is suspected the adjoining parts should be protected by “walling off” with gauze. Gauze pads, either of sufficient length to be secured with forceps or provided with tapes for the same purpose, by which their loss in the abdominal cavity may be prevented, are now used almost to the exclusion of the flat sponges formerly employed, for they are more reliable when properly sterilized. With a sufficient number of these spread out as carefully as may be, a neat padding or protective wall of gauze is made and formed around the focus of disease, into which any discharge of blood or pus may take place, and by means of which contact of surfaces is prevented. Sometimes a large amount of gauze is needed for this purpose, and when the abdomen is widely open sterile towels may be used. The greatest care should be given that nothing be left within the abdomen at the completion of the operation, and every loose piece of gauze should be secured with forceps and every towel accounted for. By this protective “walling off,” spreading of an infectious process may be prevented, as also the distribution of infectious material. The gauze should be changed as often as needed and there is often no apparent limit to the amount that may have to be employed. Advantageous as the process may be, it has its disadvantages, in that material so employed is a source of irritation and is practically a foreign body, intruded within the abdomen in such a way as to have always a depressing influence. This depression, however, is but temporary, and is the lesser of two evils, and in the presence of pus can scarcely be avoided. Instruments, especially the smaller ones, should also be counted before and after operation, or be so accounted for that none may remain or be lost.