The principles and practice of modern surgery

by Roswell Park

Strangulated hernia, then, being always a dire emergency, is in nearly every instance best treated by herniotomy, whose principles are the same, no matter whether applied to inguinal, femoral, or umbilical hernia. By a suitably planned incision the sac is exposed. In the inguinal region this follows the general direction of the cord and inguinal canal. In the femoral region it is best to raise a flap, while in umbilical hernia, although the first incision may be in the middle line, it will usually be found necessary to make an elliptical excision of the overlying skin, in order that both it and the sac may be removed. Under conditions of long existent hernia, plus strangulation, the original anatomical conditions are much altered, and it is not necessary to waste time in the endeavor to recognize the various coverings of the sac. One cuts directly down upon it with such care that he may recognize it as he comes upon it, usually by its color and by the sensation of proximity to its strangulated contents. This is ordinarily not a difficult matter; all bleeding vessels should be secured before the sac is finally opened. Final and complete identification may be made by finding that the sac itself may be pinched up between the fingers or forceps, while the underlying contents slip away. Only when parts are bound together in exudate will there be difficulty in this regard. The surgeon should still proceed with caution, although the sac will usually contain sufficient fluid of transudation to protect against injury to the enclosed bowel. Nevertheless the greatest care should be observed not to wound the intestine, which sometimes lies very closely under the skin, especially in the middle line of an umbilical hernia, although there may be masses of fat on either side of it. Sometimes the sac distended with discolored fluid is itself mistaken for the bowel. Error can usually be avoided by following it upward and identifying its continuity with the surrounding tissues.

When opened its contained fluid may be found quite clear, blood-stained, purulent, extremely offensive, or even fecal, according to the relative age of the condition and the degree and results of strangulation. Under all circumstances it is advisable to disinfect the sac and its contents before endeavoring to release them. This may be done with dilute peroxide of hydrogen or with any ordinary irrigating fluid.

Within the sac, when thus identified and opened, may be imprisoned omentum or bowel, or both, in any degree of preservation from that which is almost normal, and with circulation but slightly disturbed, to that which is absolutely gangrenous. Congested bowel will nearly always be more or less discolored. So long as it is dusky or even almost black, but has not lost its luster, it may probably be safely returned to the abdominal cavity; but if green or if luster be gone, or if the contained fluid be distinctly putrefactive, then serious doubt as to its viability will arise. In case of actual perforation, gangrene, or fecal abscess there will be no doubt as to the danger of returning such bowel, and other measures should be adopted.

The viability of the bowel having been determined and the sac disinfected the location and degree of tightness of the constricting ring should now be determined. In inguinal hernia the constriction may occur either at the external or internal ring; in femoral hernia it is usually at the femoral ring; in umbilical hernia, at some portion of the umbilical opening; while in all three forms constriction may occur within the sac itself and with little reference to the ordinary hernial outlets; all of which needs to be clearly kept in mind. This identification is usually done with the tip of the little finger, gently insinuated and used as a probe. The operator who is sure of his methods does not necessarily need to expose the constricting ring in order to nick it or divide it, but he who is not as proficient should extend and deepen his incision until the parts are clearly exposed, so that he may be sure of not doing more harm than good.

Ordinarily it is necessary only to nick at one or two points the margin of the ring, which will feel much like a wire loop, and then to use the finger as a dilator, stretching and perhaps tearing, i. e., making the knife do as little and the finger as much work as possible, in order to so loosen up the constricted canal that by gentle taxis or manipulation reduction can now be accomplished. The text-books on anatomy give minute descriptions of the relations of these hernial outlets to important bloodvessels, with which even the student should be perfectly familiar. Nevertheless by following the subjoined rule, and never departing from the principle thereby indicated, the operator may safely proceed in practically every instance. This is to cut in the direction of the patient’s nose. The knife used for this purpose is ordinarily the herniotome, i. e., a blunt, slightly curved bistoury, with but a small exposed cutting blade, whose dull point is passed along the finger until the constriction is reached, and then, by the sense of touch, beneath and beyond it, until the wire edge of the ring rests upon the cutting part. The handle is then turned until this edge points upward and is moved with a gentle sawing action always in the above-specified direction, until the peculiar resistance is felt to have yielded. It may then be turned a little and another nick be similarly made. These nicks should not be more than one-quarter of an inch deep, after which the knife is withdrawn and the finger now made to dilate and tear. With these precautions there is very little danger of dividing an anomalously placed vessel.

Dilatation of the ring being now sufficient it is well to pull the hernial mass a little downward, in order that the condition of the bowel at the point of constriction may be exactly noted. It should therefore be gently coaxed into the wound, once more subjected to inspection, and then to disinfection. The surgeon should now determine what to do both with the bowel and the omentum. Omentum which is covered with exudate or darkly discolored, or surrounded by offensive material, should be first liberated, then ligated, above the original point of constriction, and the undesirable part removed, the stump being returned to the abdominal cavity. The bowel, if decided by above indications to be viable, may then be gently coaxed back if handled with care.

But gut which has perforated, or is so compromised as to be threatening gangrene, should not be returned into the abdominal cavity, but treated by resection, or by fixation and the formation of an artificial anus, decision depending both upon the condition of the patient and of the bowel. Some of these cases are too nearly moribund when operated to justify such procedures as resection, and are suffering too profoundly from the consequences of obstruction to make it advisable to do more than open the bowel for its immediate relief. Artificial anus is, therefore, the inevitable necessity in some forms of strangulation. When the bowel is gangrenous it is not necessary even to endeavor to draw it farther down into the sac, but it may be simply opened in situ.

Intestinal resection and suture instituted under these circumstances are essentially the same as those already described in the chapter on the Small Intestines. With the formation of an artificial anus there results the inevitable fecal fistula which will require subsequent operation, probably secondary resection.

In non-septic and favorable cases, the reduction having been accomplished, the operator then may proceed to extirpation of the sac and the closure of the hernial outlet, i. e., operate for radical cure, this being a modern extension and addition to the old operation for relief.

If obstructive symptoms should persist after operation the possibility of twisting of the intestine, or a possible reduction en bloc, may be feared, which is not likely to occur if the open part of the operating have been done thoroughly.