When the gall-bladder has not been fastened nor allowed to adhere to the skin, but only to the peritoneum, the fistulas thus made will usually close and rarely need stimulation. Should, however, the granulation process by which closure is effected be too sluggish it may be stimulated by the application of nitrate of silver, either in solution upon a swab, or in solid form, as when melted into a bead upon the end of a suitable probe. Firm pressure will also assist in final closure.
It is not reasonable to expect that after so much intervention, within the rudely triangular potential cavity occupied by the gall-bladder and the ducts, adhesions will not form as a part of the reparative process. In fact it may rather be expected that as it becomes obliterated adhesion must necessarily follow. In consequence there may result an agglutination around the gall tract, and into a common mass, of the liver, the colon, and the pyloric end of the stomach. In spite of these adhesions bad symptoms rarely ensue, and when discomfort persists it is usually in those cases in which no stone was found or those in which stones have been overlooked. Andrews regards such postoperative adhesions as unavoidable and even desirable, and, having no faith in any measures to prevent their formation, differs from Morris in regard to the technique of their subsequent removal. It appearing from observation and experience that the stomach is the organ which suffers most by extensive adhesion to the liver, he has proposed to substitute the colon for the stomach in this necessary union of surfaces, and would even practise it in old cases after separation of old adhesions.
The operation suggested by Andrews, and which he calls cholehepatopexy, or colon substitution, is made with an incision through the middle line of the right rectus, avoiding any old scar, long enough to afford plenty of room. The stomach is then carefully separated from the liver, tearing liver tissue rather than that of the former, if something must be torn, and checking bleeding by hot sponges. The pylorus having been exposed the stomach is invaginated into it in order to demonstrate its patency. The freshly separated viscera will now fall again into immediate contact unless the transverse colon be pulled up and held in place between the liver and the pylorus, this not being so much of a displacement as would appear, as the bowel is not rotated and does not cross over the stomach. The colon is held in its new relation by attaching its omentum to the gastrohepatic ligament, to the liver surface, or to remnants of old adhesions in the angle between the pylorus and the liver. The looser the omentum and the more easily it can be interposed in this way the better. Andrews’ conclusions are that gall-tract adhesions are unavoidable, both in disease and after operation, that they are harmless except in a very few cases, and often beneficial, and that in the few cases where they do harm this comes from malposition rather than from adhesions per se. He even believes that certain vague gastric adhesions which might have been benefited by this operation have been previously treated by gastro-enterostomy.
CHAPTER LIII.
THE OMENTUM, THE MESENTERY, THE SPLEEN, THE PANCREAS.
THE OMENTUM.
The omentum is something more than what it generally appears, i. e., a more or less thick and extensive apron of fat, hanging down in front of the small intestines, although in this respect alone it serves as a sort of reservoir or storehouse for fat, which is always drawn upon as the needs of the system may require. The omentum varies within wide limits from being the flimsiest veil of peritoneum, whose four original layers have become so blended as to be lost to recognition, and which may even be perforated in places with openings through which strangulation of the bowel is possible, to the thickest and grossest mass of fat found in the human body, resembling a coarse mat rather than any finer texture, and having a thickness, in obese individuals, of two to four inches. Under these circumstances it makes a formidable obstacle to nearly all abdominal operations. The thickness of the omentum sustains usually a pretty constant proportion to the amount of adipose between the skin and the abdominal muscles. In certain enormously fat individuals one has then to go through from four to six inches of tissue, mostly adipose, before reaching the rest of the abdominal contents. This necessitates a longer incision and is always a disadvantage and impediment. To the operating surgeon, then, the omentum sometimes appears a nuisance.
It does not deserve, however, to be so regarded, and when properly viewed the omentum will frequently appear in the role of the surgeon’s as well as the patient’s best friend. This is due to its power of shifting itself, and, as it were, enclosing actively dangerous foci due to any variety of infection, the natural intent being, as it were, to wrap itself around and thus completely imprison the source of the trouble, a fact which is often actually accomplished, and by which life-saving protection is frequently afforded. This is true of the omentum whether thick or thin. By virtue of the adhesions which often annoy the surgeon, and which necessitate separation and perhaps considerable work before the actual trouble is exposed, a protective barrier is formed and the greater portion of the abdominal cavity shut off from danger of spreading infection. Moreover, that the omentum has a really valuable purpose appears from the fact that its removal from young animals seems to cause retardation of development, and from adult animals a diminution of resistance to the action of poisons introduced into the peritoneum. It is the omentum which, to a large extent, absorbs foreign corpuscles, such as those from extravasated blood. It helps, moreover, to dissolve blood clots and to facilitate their disappearance, and after the removal of the spleen it would appear to vicariously perform at least some of its duties. Thus when the complete blood supply of the spleen is cut off the organ almost completely disappears as the result of its absorption by the omentum. (This at least in experimental animals.)
The omentum serves further useful purpose by plugging various openings and wounds in the abdominal walls, and thus affording at least a temporary protection, just as the mucosa sometimes acts in reference to the stomach. Moreover, it is so vascular, so flexible, and so available that it may be used for plastic purposes in covering weak spots, lines of sutures, and the like, in the small intestine or even elsewhere. These same physical qualities make it extremely prone to escape through the natural outlets. Hence the frequency of epiplocele or [omental hernia] (q. v.). By a species of such hernial protrusion it has saved many a life after bursting open or re-opening of recent abdominal wounds. Sometimes it will escape after removal of a gauze drain which has not been judiciously placed and protected, this accident then constituting one variety of postoperative or traumatic hernia.
By virtue of its adhesions, which at first are short and flat, but which later become stretched into bands, obstruction of the bowels may be produced, or by atrophic or absorptive processes openings or windows may occur in it with the same result. When participating in septic processes it becomes infiltrated, is often covered to a large extent with breaking-down lymph, and may become gangrenous. All portions thus compromised are best tied off and removed when exposed during operation. Nevertheless the omentum should be gently handled, because its venous walls are thin and liable to rupture, and its bleeding points should be carefully secured, especially after separation of adhesions.