Abdominal drainage may be favored by one other expedient—i. e., position. The peritoneum possesses unusual powers of absorption and is capable of taking care of morbid material up to a certain point. It has been shown that the peritoneum of the upper abdomen especially, even that lining the diaphragm, is particularly potent in this direction—next to it perhaps that of the pelvic cavity. Septic processes in the upper abdomen are then sometimes advantageously dealt with by placing the patient in bed in a position with the pelvis considerably elevated and the head dependent. This is the more valuable after irrigation has been practised, where there may be considerable fluid which may thus gravitate. On the contrary, in serious septic pelvic infections it is often good practice to keep the patient in the semisitting posture, so soon as sufficiently recovered from the anesthetic. (Fowler.) These expedients are perhaps the more valuable when provision is made in either one of the dependent portions for drainage, gravity thus favoring the accumulation of fluid where it can be best cared for.
CLOSURE OF ABDOMINAL INCISIONS.
In what may be termed a clean abdominal operation it is seldom that drainage is provided. Such cases are expected to heal promptly and the wound to close immediately and without pus formation. It is only in cases where drainage has been necessitated that there is a really legitimate excuse for subsequent yielding of the scar, and the production of postoperative ventral hernia. These at least are the ideal and theoretically correct notions, although it should be acknowledged that in the practice of even the most competent such undesirable sequels as ventral hernia do sometimes occur. Foreseeing the possibility of their occurrence and realizing the conditions which permit the same, every known precaution should be taken. The question then of the method of closure of even a small abdominal wound is one of great importance, which has long engaged the attention of the most experienced operators, who have not yet united upon what all consider the ideal or perfect method. In general it may be said that suture of each separate tissue layer comes nearest to this ideal, along with the employment of a suture material which should serve its purpose sufficiently long, and yet not remain as a possible future irritant. When time is afforded, and there are no contra-indications, the following may be given as the best directions in this regard: A suture of the peritoneal edges, with or without the deep fascia. In or near the middle line the posterior sheath of the rectus may also be included in this row. These sutures should be inserted with extreme care so as not to include any peritoneum of the bowel surfaces. Then the muscle edges are brought together by a second row, over which the deep aponeurosis is covered and brought together with a third row. Rather than fail in accurate approximation of this third row it would be better to overlap the edges and fasten them together in this position. These sutures should be made with hardened catgut, of whose sterility and durability there is no question. It should have been so treated that reliance may be placed on its remaining for at least twenty days. The method with the balance of the wound may depend to some degree upon its thickness. In individuals with fat abdominal walls it is better, in order to avoid dead spaces, to insert one or two rows of buried sutures, by which the fatty surfaces are brought into contact. Finally the skin margins may be approximated, either with a subcutaneous chromic or silkworm suture, or by the ordinary continuous or interrupted suture, which may be made, according to choice, of celluloid thread (Pagenstecher’s linen thread soaked in a celluloid solution and thus made non-absorbent), sterile silk, or fine wire.
The nature and the location of the incision and the thickness of the tissues, along with the degree of tension which may be made upon them, will to some extent determine how the more superficial stitches may be placed. The depressing effect of postoperative vomiting may be forestalled by placing another set of three or four mattress or quilted sutures, which may be brought out at a distance of two or three inches from the incision and guarded with shot, plates, or rolls of gauze. These sutures have a tendency to take off tension from those immediately closing the wound and are a valuable means of securing primary union.
Ordinarily, as stated above, one never drains the abdominal wound proper. Nevertheless if it has been infected by contact with gangrenous or infectious material it is better to leave some opening for escape, or else, as a final precaution, to trim the surfaces which have been exposed and bring into contact only those which are absolutely fresh and uncontaminated. In gunshot wounds, for example, unless the track of the missile has been cleanly excised some provision should be made for drainage thereof.
A further protection should be, however, afforded in the dressings, by strips of plaster placed over the deeper dressings, by which again tension is taken off the wound, and still further by such snug bandaging and arrangement of compresses and dressings as shall complete this protection.
There are occasions when this procedure, which necessarily consumes a little time, cannot be completely carried out, and when there must be haste in order to get the patient off the table in suitable condition. In such cases the operator usually contents himself with the application of silkworm-gut sutures, which include the whole thickness of the abdominal wall, or the use of secondary sutures, which can be tightened and utilized later. As Binnie has said: “Inexperienced surgeons, after completing a prolonged operation on an exhausted individual, sometimes forget that it is better to have a postoperative hernia in a living patient than a perfectly closed wound in a corpse.”
AFTER-TREATMENT OF ABDOMINAL OPERATIONS.
While in the general principles regarding the after-treatment of abdominal cases practitioners are well agreed, the world over, they differ so in regard to minor points that it is difficult to give explicit directions which shall be acceptable to all. Much will depend upon whether the patient has had suitable preliminary preparation. If, for instance, the bowels have been thoroughly emptied there need be no haste to administer laxatives, as though this had not been the case. In many instances where this precaution has been neglected catharsis is, after operation, the most important consideration, and yet this may be difficult to secure, the difficulty being enhanced by the fact that an individual just operated on and extremely tender finds it difficult to give natural assistance to the process of defecation. The matter is particularly complicated by the difficulty of selecting an active cathartic which may be retained by a sensitive stomach. One of the greatest needs of the surgeon, as well as of the physician, is a suitable medicament of active cathartic properties which can be satisfactorily administered with a hypodermic syringe. Nothing of this kind is as yet known.
It is good practice in many cases to throw into the intestine, through a fine needle connected with a large syringe, a considerable quantity of saturated solution of Epsom salt before closing the abdomen. This places it where it will not be rejected by an irritable stomach, and where it must have the desired effect. The needle so used should be carefully introduced, in a very oblique direction; while should the minute puncture bleed or seem to leak it may be included in a suture or ligature loop, which should take up the peritoneal coat only. In addition to this, an occasional expedient, the writer usually administers, before the patient leaves the table, a subcutaneous injection of ¹⁄₅₀ Gr. of eserine sulphate, the active principle of Calabar bean, this being a powerful stimulant to the muscular coat of the intestine. The bowels should be thoroughly emptied in the easiest manner after every operation.