[58] Sanderson has suggested a new method of sterilization of the interior of the bowel at the time of operation. He injects a solution of acetozone through a hypodermic needle, or, after opening the bowel, freely irrigates with the same.
One of the greatest difficulties attendant upon the operation is the avoidance of all contamination by contact of peritoneum with intestinal contents. Against this the most minute precautions should be taken. This is never an easy matter, and in the presence of distended bowels and the emergency of acute obstruction it sometimes taxes every resource at hand. A variety of clamps have been devised by different operators, the intent being to so clasp the bowel beneath their blades as to completely occlude it. These blades are covered with sterilized rubber tubing to keep them from acting too harshly, and it is necessary to use pressure upon the handles with great discretion, lest permanent injury be done to the bloodvessels. The bloodvessels of the bowel are essentially terminal, and the blood supply should be kept sufficient for every part which is not removed. These vessels are, moreover, numerous and relatively large, and hemorrhage is not always easy of control, especially when clamps are not at hand. As a substitute for clamps tapes of sterilized gauze may be used, being tied around the bowel, or the fingers of a reliable assistant may be substituted. Such use of the fingers is not easy nor simple, not only because they become tired and relax their grasp, but since they slip so easily, and because the escape of one drop of fecal matter may cause a fatal contamination.
Resection of the bowel may imply in one case a removal of but two or three inches of its length, while the other extreme is not reached until several feet of bowel have been removed. I have been able to successfully remove eight feet and nine inches of intestine, the lower part including the cecum and a portion of the ascending colon, and there are now on record nearly twenty cases where over 200 Cm. of bowel have been resected, nearly all of them recovering. Success in this procedure depends partly upon the condition necessitating the operation, as well as the general condition of the patient, but in no small measure hangs upon the perfection of the operator’s technique.
Fig. 575
End-to-end or circular anastomosis by enterorrhaphy. First row of distal sutures in serosa. (Type of needle differs from that used in this country). (Lejars.)
Fig. 576
Completion of last row of sutures, begun as shown in [Fig. 575]. (Lejars.)
Whatever be the condition which requires such resection it should be made sufficiently extensive to completely include and permit the total removal of the diseased or injured portion. The abdominal incision should be large enough to permit the delivery upon the surface of the body of all that portion to be removed. Unless this be done the difficulties are greatly enhanced. Save where there is some distinct indication for opening elsewhere, this incision is made in the middle line. The compromised bowel having been sought and thus delivered and one having decided exactly where to divide it, clamps are so placed both above and below each line of division as to prevent leakage. Underneath the bowel to be thus divided gauze is placed in such a way as to receive the small amount of discharge which will escape from the portion between the clamps. The exposed bowel surfaces should then be thoroughly cleaned, the contaminated gauze removed, fresh pieces substituted for it, and the other division of bowel made in the same way. While in some cases it may be well to tie off the mesenteric border and secure all its vessels before dividing the bowel, this may at other times be delayed until after the division. At all events it is the next step. Whether the mesentery shall be simply separated along the intestinal border and tied off in small portions, one after another, or whether a triangular resection of a portion of the mesentery itself should be made, securing the larger vessels nearer to its root, will depend on the nature of the case and upon whether the mesentery itself be involved in the disease. In dealing with cancer it is often necessary to remove, at the same time, every enlarged lymphatic. It may be inferred that no incision or tear, no matter how short, can be made in these tissues without danger of subsequent hemorrhage unless the parts be secured against it. A series of ligatures and sutures is therefore called for here which may consume no small proportion of the entire time of the operation. (See [Figs. 575] and [576].)