Fig. 582
Enterostomy; fixation of margins of opened gut to skin. (Lejars.)
Enterostomy.
—Enterostomy for establishment of fecal fistula, or artificial anus, is performed for relief purposes and sometimes as an emergency measure. It consists in attaching some portion of the bowel, naturally that above the constriction or disease which compels the operation, to the parietal peritoneum through a small wound in the abdominal wall. When the large intestine is opened for this purpose the operation is usually referred to as a colostomy, and this preferably is done in the left iliac region. When enterostomy of the smaller bowel is preferable it may be done at any point on the abdominal surface. Thus if through a median incision a condition be found necessitating it the bowel should be attached at the lower end of the abdominal opening, for here drainage will be better and contamination less likely. When enterostomy is done for acute obstruction, it is preferable to place the opening in one iliac fossa or the other.
Enterostomy consists essentially of the following steps: opening through the abdomen, recognition of the parietal peritoneum, which is seized with forceps on either side, opened and secured with these forceps, after which the first tensely distended loop of bowel which presents is taken, and, with a series of fine sutures in a round needle, the serous surface of the gut is attached to the margins of the parietal peritoneum ([Figs. 581] and [582]). In the more desperate cases a portion of the bowel may be brought out through the wound and fixed there in such a way that it cannot recede. If the emergency is great the bowel may be immediately punctured, the patient so placed and so protected that fecal contents shall escape away from the body rather than over it. If one can take a little time he may wait a few hours for the adhesion which is sure to take place between the peritoneal surfaces and the consequent shutting off of the abdominal cavity from the outer wound. Thus after twelve hours the surface of bowel exposed through the wound may be punctured either with a knife, scissors, or the actual cautery, and this may be done without causing pain to the patient. Escape of bowel contents will instantly ensue after puncture. After permitting all to escape that will, abundant protection should be provided for the reception of the discharges, which will continue at reduced rate. The best way to do this is to pass into the bowel in the proper direction a rubber tube, as large as it can accommodate, or a glass tube, bent at an angle, which shall connect with a flexible tube, and thus conduct away all discharge.
Another method of performing the operation is to bring out the loop of bowel, open and empty it, then to introduce a glass or rubber tube, around which is snugly fastened the bowel margin. The intestine is then stitched in place and the tube so arranged as to conduct away all discharge.
Just how much may be expected of such a relief opening will depend upon the case. These operations, especially for cancer of the rectum or the lower bowel, may prolong life for two or three years. An emergency opening into the small bowel for relief of acute obstruction may need to be kept open for but a few days, after which the tube may be removed and the fecal fistula be allowed gradually to contract. According to the case an intestinal resection may be made or the opening may be closed by one of the plastic methods.
Appendicostomy.
—Appendicostomy is the more complete form of carrying out a suggestion first made by Hale White, of opening the colon on the right side in cases of intractable colitis. Gibson suggested to accomplish this by a method similar to Kader’s for gastrostomy, making a valvular colostomy through which the colon might be irrigated, without escape of feces. In 1902, Weir, intending to do this operation, found the appendix rising so invitingly into the wound that the inspiration occurred to him, and was promptly acted upon, to utilize it for the purpose.