Misplaced viscera. In addition to tumours and normal enlargement of the uterus due to pregnancy, or an overfull bladder, there are certain malformations as well as displacements of normal viscera the surgeon may encounter in the pelvis which will, in some cases, cause him a certain amount of embarrassment, such, for example, as a bifid uterus or a spleen which has elongated its pedicle, or even twisted it, and, falling so low in the abdomen as to occupy the pelvis, may even cause prolapse of the uterus. In some of these cases it drags the tail of the pancreas with it. The cæcum and the vermiform appendix often occupy the true pelvis; in middle-aged and elderly women the transverse colon sometimes forms a loop (the omega-loop), the extreme convexity of which often reaches to the pelvis. I have seen the right lobe of the liver extend into the pelvis, and come in contact with the unimpregnated uterus. It is important to remember that a kidney sometimes occupies the hollow of the sacrum; such a misplaced kidney has been removed under the impression that it was a tumour. When a kidney occupies the pelvis it lies behind the peritoneum as when it occupies its normal position in the loin. A horseshoe kidney is a fertile source of divergent opinion in diagnosis. A very large hydronephrosis simulates very closely an ovarian cyst until exposed through an abdominal incision; in such a contingency the operator performs nephrectomy; when the kidney is large enough to resemble an ovarian cyst it can easily be removed through the median incision.
A very distended stomach will reach the hypogastrium and has many times been mistaken for an ovarian cyst; such a distended stomach has received a thrust from an ovariotomy trocar and the operator has been astonished to see food issue through the opening.
Tumours of the pelvic organs are often complicated with abnormal and diseased conditions of the intestines, large and small; it is therefore necessary for any one undertaking gynæcological abdominal operations to be prepared to perform resections of the colon, enterorrhaphy, gastro-jejunostomy, and the like when necessary.
Transposition of the viscera is a rare anomaly to encounter in the course of an abdominal operation. I met with it once in 3,000 cœliotomies; the condition was recognized before operation.
Closure of the wound. There are about fifty methods known and advocated for the closure of the median subumbilical incision, and the following is a list of materials used by surgeons for this purpose: silk, silkworm-gut, catgut, linen thread, and horsehair; silver, iron, aluminium, bronze, and platinum wire, and Michel’s metal clips. The object of these various methods and materials is to obtain a firm scar.
The first requisite for securing an unyielding scar is perfect asepsis; but even the most perfectly healed abdominal scar may yield. Nature in her great operation of uniting the lateral halves of the belly-wall in a median cicatrix, the linea alba, cannot secure a non-yielding scar, it is therefore presumptuous of the surgeon to think he can always ensure it.
The method which has given me the best results is a simple one. The peritoneum, sheath of the rectus, and rectus muscle are carefully approximated by interrupted sutures of No. 4 silk carefully sterilized and inserted with the hands covered with rubber gloves. The sutures are inserted at intervals of rather less than 2 centimetres apart. Care must be taken to include the peritoneum in these sutures. The skin is then brought together by a continuous suture of No. 2 silk. When the operation has been undertaken for a septic condition, such as pelvic peritonitis, suppuration of an ovarian cyst, an acute pyosalpinx, or the like, then it is useless to introduce buried sutures for the muscular and aponeurotic layers, as they will quickly become infected. In such conditions the abdominal walls are brought together by interrupted sutures involving all the layers.
Those who are curious in regard to the various methods of closing median cœliotomy wounds should consult a brochure published in 1904 on The Closure of Laparotomy Wounds as practised in Germany and Austria, by Walter H. Swaffield. This little book contains the detailed methods and views communicated to him by more than fifty leading surgeons.
In Great Britain there is plenty of variety in the methods and material employed for the closure of the incisions in abdominal operations, but at the present time there is a marked tendency to return to the older and simpler methods. The most dangerous and unreliable suture material for the abdominal incision is catgut (see [p. 96]).