The principles and practice of modern surgery

by Roswell Park

The small area included under the above title has been made the field for a variety of operations, dignified with formidable names, the entire list of which might be made quite long. In order to simplify their arrangement and illustrate their purposes they may be referred to as (1) operations upon the gall-bladder proper; (2) those upon the ducts; and (3) the more complicated operations upon one or both of these in connection with some other part of the intestinal tract; or, to catalogue them somewhat definitely, the operations upon the gall-bladder include cholecystotomy, cholecystostomy, and cholecystectomy, according as the surgeon opens the gall-bladder and closes it, makes a more or less permanent opening, or completely removes it. Again, upon the ducts he may make cholangiotomy or cholangiostomy, or, using their practically equivalent synonyms, choledochotomy or choledochostomy, these terms referring to operations upon the cystic and the common ducts; while when similar procedures are applied to the hepatic duct they have been spoken of as hepaticotomy and hepaticostomy. Cholecystenterostomy refers to an anastomosis between the gall-bladder and the upper bowel, while when this is effected between the common duct and the bowel it is referred to as choledochenterostomy. When a stone lies partly in the common duct and partly within the wall of the duodenum, and it becomes necessary to incise the latter, it may be spoken of as duodenotomy. The operation of merely crushing biliary calculi, hoping that the fragments will be passed on with the flow of bile, and spoken of as cholelithotrity, is now almost abandoned, and the term has historical rather than present value.

To even attempt to epitomize directions for these various operations into space available here would be impossible, for large volumes have been devoted to this subject alone. The main thing for the student and the junior practitioner is to appreciate the indications for their performance, at which he should certainly have assisted before attempting to perform them himself. General directions, however, may be given as follows, the usual preparations having been made both of the patient and the environment: A woman who has borne children and who has, in consequence, relaxed abdominal walls, makes a more favorable subject for operation than a muscular man whose abdominal muscles cannot be relaxed until a profound degree of anesthesia has been obtained. In many instances exposure is made better by placing a sandbag behind the region of the liver, especially on the side to be operated, by which the costal angle is more outlined and the parts pushed forward.

A preliminary incision should be made of, say, three inches in length, and is best placed a little to the inner side of the outer border of the rectus, whose fibers are separated and its tendinous intersection divided. This incision may be extended upward and curved toward the middle line, as recommended by Bevan, or downward, as the exigencies of the case may require. The beginner especially should provide himself with sufficient space for manipulation. The posterior sheath of the rectus and the peritoneum are best divided together. Sufficient opening being thus made, a finger may be inserted for the purpose of exploration. In the presence of adhesions, and especially in acute cases in which pus is likely to be present, this should be done with great caution. When no adhesions are present gauze pads may be inserted and so disposed as to permit exposure to view of the lower surfaces of the liver. The operator should be prepared for any and all conditions—one of dense adhesions or their complete absence, as well as for cobweb-like adhesions which surround foci of infected exudate or of pus. The more reason he may have for suspecting the presence of pus the more carefully should the region be walled off with protective gauze. Adhesions are most likely to form between the omentum and the colon, in front and below, and with the stomach, duodenum, and colon below and behind. Those who have had experience with abdominal operations will appreciate whether these adhesions are recent and likely to cover purulent foci, or old, and will proceed accordingly. Occasionally tissues will be so matted that even an experienced operator will scarcely be able to differentiate them.

The endeavor should be, if possible, to expose the gall-bladder itself, both to touch and sight, in order that after orientation concerning its actual condition its duct may be followed into the common duct, and this into the intestine. This is sometimes an exceedingly easy matter, and again impossible. The presence or absence of pus will of itself indicate what should be done. When, for instance, the gall-bladder is found black or partly gangrenous the surgeon will content himself with doing the least possible amount of separating, endeavoring rather to provide the widest outlet for drainage. It might be better to make simply a small opening and permit the escape of fetid débris, and to postpone until a later day further attempt to remove the calculus, which presumably has produced the difficulty. Local indications, then, should be considered along with the general condition of the patient.

The lower surface of the liver will afford the guide to the location of the gall-bladder, and when the latter is nearly obliterated its discovery sometimes taxes the resources of the surgeon. When not contracted it is usually easily exposed, and so far freed that it may be even drawn up into the wound. After having thus isolated and perhaps secured it, it must be decided by further exploration how it shall be treated. It is of great importance to liberate the ducts from surrounding adhesions.

Cholecystotomy.

—Cholecystotomy, sometimes fallaciously spoken of as ideal, consists in simply opening the gall-bladder, emptying it of calculi or other contents through a small incision, and closing this by sutures. The operation is ideal in but one way, but conditions which permit it rarely justify it, for any gall-bladder so diseased as to call for operation needs either removal or drainage.

Cholecystostomy.

—Cholecystostomy includes provision for drainage over a considerable length of time. A distended gall-bladder which permits of easy manipulation and isolation may be sufficiently long and large to justify uniting its surface to the peritoneum and deep margins of the wound, in such a way as to permit discharge of its contents through the latter. The old method was to unite it to the skin. This should never be done, as fistulas thus resulting are more likely to be permanent. If the gall-bladder be thus affixed to the parietal peritoneum the better way is to insert a drain, its arrangement being left somewhat to the choice of the operator. For my own part I prefer a rubber tube, not too flexible, inserted two or three inches into the gall-bladder, through a small opening closed around it, with invaginated edges, by a purse-string suture of chromic gut, by which it is intended to prevent leakage into the abdominal cavity. By another suture of common gut the tube may be so fixed as to avoid danger of being lost in either direction. If the gall-bladder be sufficiently long to permit additional fixation to the depths of the abdominal wound the operation is made still more ideal; but in the case of a short and contracted cavity the tube may be left to follow it into the abdominal recesses. Within forty-eight hours the exudate which has been thrown out around it will have become sufficiently organized and well ordered to form a canal in which the tube shall rest, and which shall serve later as a conduit to conduct bile to the surface after removal of the tube itself. Into such a tube, after the application of the dressings, may be conducted another more flexible tube, whose upper end shall connect with a receptacle of some kind, which may later be a bottle held within the dressing, to receive the discharge, and thus avoid soiling.

This operation has been done occasionally in two sittings, the gall-bladder being brought into the upper part of the wound and fastened to the peritoneum by sutures, which should not perforate its walls, as that leakage would occur which the method is intended to avoid. After waiting a day or two for adhesions to form the cavity is then opened with a knife or scissors and drainage thus accomplished. This method has been practically abandoned, for the reason that it permits no digital exploration by combined manipulation.