Graser’s method of dealing with umbilical hernia.
In many inguinal and umbilical and in a few femoral hernias the operator will be hampered by adhesions between the omentum or between the bowel and the sac wall. These may be infrequent and slight or extensive and dense. They are relatively unimportant so long as they involve only the omentum, which may at any time be cut away, the stump being dropped back into the abdomen, after being suitably secured; but when bowel, especially large intestine, is thus adherent, great care should be exercised, avoiding all possibility of shutting off the blood supply while securing every divided vessel.
Particularly is this true in treatment of umbilical hernias, either radical or under conditions of strangulation. In stout individuals, usually women, umbilical sacs sometimes contain several feet of bowel, and adhesions may be met at many points, difficulties arising not only in their separation, but in the final disposition and accommodation of all this bowel within the abdominal cavity, from which it has been so long absent. Radical cure will in these cases leave intra-abdominal viscera in a rather overcrowded condition.
The essential details of radical treatment of umbilical hernia are the same, modified by the extent of sac which has to be removed, and by the wisdom in many instances of a large elliptical excision of the overlying skin and removal of much superfluous tissue. After freeing the contents and reducing them, the sac wall being completely separated, there is the choice of two or three methods of closing the umbilical opening, either by overlapping of flaps, which may be cut from the thickest portion of the sac, which will be close to the outlet, or by dissecting them from the aponeurosis, as suggested by Mayo, and turning the upper down over the lower, or by any other expedient which individual peculiarities may suggest ([Figs. 621] to [624]). I have been able to employ, to apparent advantage, my method of securing suture material for this deep closure from the sac wall itself, this not preventing the employment of any other method or improvement.
Fig. 623
Fig. 624
Method by transverse closure of both deep and external incisions.
Ventral and postoperative hernias are operated on in essentially the same manner as the forms above described. Adhesions may be found in these cases, and plastic methods should be devised for bringing together irregularly shaped openings and holding them in the firmest possible manner. In any extensive abdominal hernia, umbilical or ventral, it is advisable to use buried sutures, closing the abdominal walls, layer by layer, and finally to insert at some distance a sufficient number of through-and-through retention sutures, guarded by plates or small rolls of gauze, these taking off tension from the wound and affording protection against any special strain, such as vomiting.