The method of performance will depend not so much upon the nature of the difficulty requiring the operation as upon the condition of the patient, the equipment, and the operative skill of the surgeon. With a patient in extremely serious condition that method which may be most quickly performed is obviously the best. When time and method are under control, then that is best which can be most perfectly performed by the operator, or that which he is compelled to adopt, as when, for instance, he resorts to a suture method because he has no button at hand.
In order to simplify the subject as much as possible the following methods alone will be mentioned here:
The method by suture is essentially similar to that described as gastro-anastomosis, the surfaces which are to be brought together being properly placed, and approximated, first, by a row of silk suture, the openings being then made with excision of a strip of mucosa, and the mucosa being next sutured with chromic gut, first on the further side, then on the near side of the opening, after which the serous membranes are accurately sutured around the opening by continuation of the first row of silk sutures. The actual opening made for the purpose should be at least an inch in length, preferably an inch and a half or more, while when the lower bowel is attached to the colon such an opening may well have a length of at least 2¹⁄₂ inches, for if successful it will be followed by a certain degree of cicatricial contraction and will never remain of its original size ([Figs. 566], [567], [568] and [569]). The suture may be combined with the elastic ligature, the method again being similar to that for uniting the jejunum with the stomach, already described. The rubber ligature used for the purpose is of the same size, and there is no difference to be made in the directions already given. The elastic ligature, however, can not be relied upon in emergency cases where it is necessary to effect a communication at once. It is serviceable only in instances where there is a leeway of at least three or four days. This method has for one of its advantages the fact that in its performance it is not necessary to clamp or secure the bowel by any instrument, simply to empty it for the moment with the fingers, it not being opened during the operation by anything save the needle puncture, which is promptly filled with the rubber. It does require, however, that the rubber used for the purpose shall be reliable and new, it being unfortunately the case that pure rubber which will last for a long time is seldom found in the market.
Fig. 566
Entero-anastomosis of intestinal loops which have been resected and the bowel ends closed; the first row of sutures has been applied and the line of opening indicated. (Lejars.)
Fig. 567
Suture of the distal edges of the mucosa.
Fig. 568