The principles and practice of modern surgery

by Roswell Park

Fig. 574

Intestinal anastomosis with a Murphy button, showing the halves in position ready to be pushed together. (Bergmann.)

End-to-end reunion can be accomplished by the same method, or the end of the small intestine may be applied to the side of the large, after a method which will be best understood by reference to [Fig. 571], it being necessary here to draw the squarely cut end of the intestine around the button with a circular suture, and, at the same time, to so grasp the button that it shall not recede into and be lost in the bowel.

Small buttons have been made for the purpose of uniting the gall-bladder to the upper bowel and extra large ones are made for the large intestine.

The particular advantage of the button method is the shortness of the time required for its performance, as it can be conducted in a few moments by one who might take four times as many minutes in using sutures. The disadvantages attaching to it are these: (1) That it depends for its success upon necrosis, i. e., of the part of the bowel included within its grasp; (2) that it might itself serve as a foreign body and produce acute obstruction, a not unknown event; (3) that it is not always at hand, especially in emergency cases, and that to rely upon it is to be limited in one’s abilities.

There is but little question that, when properly performed, the simple suture methods are the best of all, and the operator who has never seen a button used should abstain from its use. Still it has given many good results. My belief is that the better the surgeon’s judgment, and the more developed his skill, the less he will rely upon any mechanical expedient of this character, and the more upon what he can accomplish with the needle in his own fingers.

End-to-side anastomosis is in no essential respect different from resection, only it may be done for the purpose of exclusion when nothing is absolutely removed. Thus in case of cancer of the cecum a lateral implantation can be made of a lower loop of the ileum upon the side of the ascending colon, using for this purpose a button, having divided the ileum on the proximal side of the ileocecal valve, and turned in both ends and invaginated the stumps. Here one resects nothing, but makes a direct communication between the bowel above and below the cancer, short-circuiting the intestinal canal, as electricians would say, and all for the purpose of giving temporary relief. Thus end-to-side or end-to-end anastomosis may be made, according as circumstances dictate, and, if one chooses, with the Murphy button.

Resection of some portion of the large or small intestine is required under a variety of different circumstances. Thus after certain injuries, contusion and rupture, or numerous punctures or gunshot perforations, it may be decided to remove a considerable length of bowel rather than be compelled to give special attention to a number of distinct lesions, believing it a time-saving measure, and, therefore, for the welfare of the individual. The same measure will be indicated when, either by injury or disease, the blood supply of any portion of the bowel is apparently compromised or certainly shut off. Here necrosis is so certainly to be expected, or perhaps has already occurred, in such a way as to necessitate removal of whatever length of bowel may thus be involved. Several of those cases, already mentioned, which produce obstruction of the bowel will demand resection, as, for instance, when reduction of an invagination is impossible, with gangrene threatening. In a few instances extensive gangrene, precipitated by embolism or thrombosis of the mesenteric vessels, has been successfully treated by resection of considerable lengths of bowel. Again, the bowel is resected for closure of fecal fistula or artificial anus, as well as for relief of stricture due to various causes. Finally, nearly all of the tumors of the intestine itself, and especially all of the malignant forms, will require removal of at least a few inches of gut, save in those cases where this is shown to be impracticable because of the presence of cancer elsewhere, in which case it may be sufficient to make an anastomosis.

When intestinal resection is not an emergency measure there should be as much preparation as the case will permit, including lavage of the stomach, the ingestion of sterilized food, the use of antiseptics and the most thorough emptying of the bowel which can be accomplished.[58]