Fig. 565

The continuous Lembert stitch. (Richardson.)

So many different forms of intestinal suture have been devised that it is useless to attempt here to describe them all.

Any minute puncture of the bowel may be closed by purse-string suture. Any perforating wound should be not only first carefully cleansed, but also slightly enlarged, cutting away its more or less contused margins in order that fresh, viable tissue may be exposed. This is particularly true of gunshot wounds. Many of the operations now practised include inversion of the end of the bowel, a method illustrated in [Fig. 566], showing a method equally applicable to burying the stump after removing the appendix, closing the end of a portion of the small or even the large bowel.

Most operators now use for the mucosa a carefully prepared and reliable chromicized catgut, the smaller size being preferable, with the ends cut short after the knots are tied. It is well also to use for intestinal suture needles which are round rather than made with cutting edges, as by the latter openings are made larger and vessels sometimes cut, this requiring the insertion of extra sutures for their securement. Whether the operator shall use curved or straight needles, and shall do the work with his fingers or depend upon various forms of needle holders, is purely a matter of choice and training. Success or failure depend not so much upon the needle holder as upon the holder of the needle, and his care and attention to detail. In the presence of multiple lesions the procedure may have to be repeated to meet each indication.

Anastomotic Operations.

—For the general application of the principle of anastomosis to intestinal work the profession is largely indebted to Senn. The principle having been once recognized will never be rejected, but methods have already varied much from those first introduced, and will be improved by the substitution of simpler procedures for the more complex.

In general an anastomotic opening may be made between any distinct portions of the alimentary canal, and almost any one part may be thus, as it were, connected up with any other. Gastrojejunostomy has already been described. Only under compulsion does one thus connect the stomach with any other part of the alimentary canal. From the jejunum down to the rectum one may, however, effect attachments of this kind at any desired point. These operations are in the main done for one of the following purposes: