Surgical Anatomy of the Gall-bladder and of the Omental Foramen and Cavity. (Sobotta.)
The probe enters the omental (epiploic) foramen. By retraction and removal of its anterior covering the cavity of the lesser omentum (omental bursa) is exposed, revealing especially the pancreas in situ.
BILIARY FISTULAS.
These may be due to accidental injury during operation or to disease processes. They may be direct or indirect, and internal or external. An example of direct, external traumatic fistula is afforded by a cholecystostomy or a cholangiostomy; of indirect internal when the gall-bladder has burst into an abscess and this into a hollow viscus. A fistula might arise from a local abscess outside the biliary passages, later communicating in both directions, or it may be connected with the thoracic organs, with evacuation into the bronchi or esophagus, and cases are on record where gallstones have been passed from the mouth. The external or cutaneous fistulas tend in most instances to spontaneous healing, but the time required is often long. They may discharge thin, biliary mucus or true bile.
Mucous fistulas result from cholecystostomy where the obstruction in the cystic duct has not been overcome, as when it is the seat of stricture or extrinsic pressure. They cause but little inconvenience. Nevertheless if allowed to close the mucus accumulates and pain results from distention. In these cases either a small tube or drain should be worn, or a cholecystenterostomy may be made. Sometimes after the discharge of some foreign body, such as a silk ligature or small stone, such a fistula will close of itself, or it may be possible to frequently cauterize its interior with a bead of nitrate of silver melted upon the end of a probe, or perhaps by using a long curette to so destroy its mucus lining as to do away with the condition and its consequent discharge. Ordinarily cholecystostomy will not be followed by permanent or even long-continued fistula if the common duct have been thoroughly cleared, and if the gall-bladder be fastened to the aponeurosis and not to the skin. Postoperative biliary fistulas, with discharge of large amounts of bile (one to two pints per day) and their consequent inconvenience, will ordinarily not be long tolerated by the patient, who will insist on some further procedure for relief. If possible, in every such case, the real cause of the difficulty should be removed. If the ducts be cleared and stimulation with caustic be not sufficient, then the abdomen should be opened, the gall-bladder detached, and its fistulous opening freshened and sutured. If the patency of the common duct can be established this will be sufficient. Otherwise, after closing the gall-bladder, it should be anastomosed with the small intestine as near the duodenum as possible.
Spontaneous or pathological fistulas often open at the umbilicus, the disease process having followed the track of the umbilical vein up to that point. Here, too, calculi are thus spontaneously extruded, one case on record including the discharge in this way of a stone three inches in diameter. In any such case as this the fistula cannot be expected to close until the calculi are all extruded. In the treatment of any such lesion the margin of the wound and the entire track of the fistula should be carefully curetted and disinfected, as at least a part of the procedure.
Biliary intestinal fistulas, due to escape of calculi into adherent intestine, are also occasionally seen. These often form without marked disturbance until perhaps at the last, when there may be destructive symptoms, both biliary and intestinal, symptoms which will suddenly subside when perforation or passage of a calculus occurs. After their occurrence patients may enjoy some relief for a considerable time, or until the contraction of the fistula may necessitate a subsequent operation. At other times their formation by ulceration is often accompanied by severe pain and fever, and possibly even by hemorrhage. Impaction of a gallstone in the intra-intestinal portion of the common duct is perhaps the most frequent cause of this kind of trouble. Fistulas into the colon are less common than into the small intestine. Such fistulas should never be intentionally made if it be possible to utilize any part of the small intestine. Although the pylorus and the gall-bladder often become firmly united to each other gastric biliary fistulas are rare. If, however, there be vomiting of gallstones, such a sign would make it quite certain. Mayo Robson has reported one such case where he separated adhesions, pared the stomach opening, closed it with sutures, and utilized the opening in the gall-bladder for the removal of calculi and subsequent drainage, the patient recovering.
INJURIES TO THE BILIARY PASSAGES.
These are less common than injuries to the liver proper. They may be caused by penetration or by severe blows and concussion. In those already suffering from local disease accidents are more likely to be followed by rupture. Injuries have also been attributed to traction and later adhesions. The fundus of the gall-bladder is the most exposed portion; therefore, that part is most often injured; while neighboring organs may suffer simultaneously—for example, the liver, stomach, and colon.