[64] It is but fair to add that, at the same time, Delagenière maintained that since, in his opinion, cirrhotic processes in the liver are due to intestinal infection, the treatment should consist of combating this and its possible consequences, to which end he would make a temporary cholecystostomy, having found it of benefit even in the atrophic, but mostly in the hypertrophic, forms of disease. Thus in two cases of this procedure, combined with hepatopexy, the patients survived eight and two years respectively. Nevertheless he acknowledged that the best results would probably be secured from combination of cholecystostomy, hepatopexy, and omentopexy.
In brief, we may hold, with Rolleston and Turner, that it is no longer advisable to treat ascites by repeated tappings, when the patient is otherwise in fairly good general condition, for numerous surgeons have warned against repeated punctures. When liver cirrhosis can be diagnosticated with fair certainty in the pre-ascitic stage, and when there is evidence of splenic enlargement or hematemesis, operative intervention would probably succeed far better than in the later stages. So far as special indications for operation are concerned they may perhaps be listed as follows:
- 1. Thrombosis of the portal vein or its compression by inflammatory products or by tumor;
- 2. Cirrhosis of cardiac origin, of the ordinary hypertrophic or even atrophic types, as well as that due to syphilis or malarial disease;
- 3. Pseudoliver cirrhosis of pericardial origin;
- 4. Diabetes of hepatic origin;
- 5. Splenomegaly combined with hepatic cirrhosis.
If these indications be met by reasonably early omental fixation there would seem to be a well-marked place for the procedure, while they cannot give rise to any worse results than the repeated puncture methods of old.
Among contra-indications to such operations may be mentioned the presence of much biliary pigment in the urine, its absence from the feces, jaundice, or marked pigmentation of the skin, while distinct renal insufficiency would also make any surgical procedure hazardous.
The operation itself, done according to the simpler and earlier recommendations of Morrison and Talma, consists in median abdominal section, withdrawal of all ascitic fluid, and the deliberate provocation of adhesions between the diaphragm and the upper surfaces of the liver and the spleen. This is produced by vigorous swabbing to a degree sufficient to cause a little oozing from the surfaces attacked. The margin of the liver may then be fastened to the costal border. After this the anterior surface of the omentum is also scarified or swabbed and affixed to the anterior abdominal wall, which has been similarly treated over as large an area as possible, by means of catgut sutures placed to the best possible advantage for the purpose. Some operators have preferred to close the abdomen without drainage, some to insert a tube in the lower margin of the wound for a day or two, and others to drain the lower abdominal cavity through a small, distinct opening above the pubes. Theoretically much advantage attaches to permitting no immediate re-accumulation of fluid. Practically, however, danger also attaches to it, i. e., from the difficulty of so managing the dressings as to avoid infection.
Schiassi has modified the above procedure and has made an omentosplenopexy of it as follows: He makes a right-angled incision across the median line and then another several inches downward along the left semilunar. The tissues down to the peritoneum are reflected toward the umbilicus, and a transverse deep opening is made just below the horizontal skin incision. Through this the omentum is drawn upward and spread over the right portion of the exposed peritoneum, where it is sutured in place. Through another vertical opening in the peritoneum, near the vertical skin incision, the spleen is then exposed, a piece of gauze is placed under each pole of that organ, and, while thus lifted, by means of a long curved needle three to six catgut sutures are passed through it, including also the peritoneum and all the superficial structures except the skin, this being closed later and separately.
Finally, whatever operative method be selected it is important that it be done early rather than late, bearing in mind that “the resources of surgery are rarely successful when practised on the dying.”
THE MESENTERY.
No one has done more to forcibly place before the surgical profession those anatomical features of the mesentery which most concern them than Monks, who, for instance, has demonstrated the fact that the mesentery is practically an enormous fan, composed of two layers of peritoneum, between which are spread out the vascular structures and more or less fat, and whose border contains the intestinal tube. This fan at its base is but a few (six) inches in length, while along its outer border, when completely unfolded, one may measure a distance of twenty-one to twenty-three feet. Not one of the structures contained between its layers can be regarded as a negligible quantity. The arterial distribution in the mesentery is terminal in the same sense that it is in the brain. Consequently dependence can be placed only on a sufficient blood supply for any given portion of the intestinal tube when its mesentery is intact. If necessary to sacrifice a portion of the mesentery it is requisite to resect that portion of the bowel which is dependent upon it for blood. This will explain the reason why thrombosis or embolism of the mesenteric vessels so quickly determines the death of that portion of bowel supplied by the occluded branches, this being equally true of the tiny fragment known as the appendix or of the entire bowel.