A Handbook of Intestinal Surgery

Front matter

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Preface

This little volume aims at giving such a precise description of the commoner intestinal sutures that an inexperienced surgeon may readily practise the various methods on dead intestine before performing an anastomosis on the living subject.

The book owes its origin to the establishment of a class in intestinal surgery at the West London Post-graduate College, and it contains a full description of the work done in this class. The material which I use for these classes is the small intestine of bullocks, which I am fortunate enough to obtain the day the animal is killed. Bullock's intestine is of practically the same thickness as that of man, and if used quite fresh resembles to the touch and in resistance the intestine of a living man much more closely than does human intestine removed in the post-mortem room. It, moreover, has the advantage of being odourless and of not soiling the hands. In order to enable an anastomosis to be performed single-handed, each student is provided with a little intestine holder, which is figured on p. 43, and takes the place of a firstrate assistant. In such a book, with the aid of which, it is hoped, the student may dispense with class teaching, numerous and clear illustrations are of the first importance, and I have been very fortunate in obtaining the assistance of Dr. Leonard Mark and of my colleague, vi Preface

Mr. A. Baldwin, to whose artistic illustration^ much of he usefulness of the book will be due. I have to acknowledge the courtesy of my friend Mr. Watson Cheyne, and of Messrs. W. B. Saunders and Co., who have kindly allowed me to copy the diagrams which bear their names. I have also to thank Dr. Maunsell, Mr. Jessett, and Messrs. Down Bros, for the loan of a number of blocks.

The last two chapters on the preparation before and the treatment after operations are lectures delivered at the Post-Graduate College, and were originally published in the Clinical Journal,

L. A. BIDWELL.

Mayy 1905.

Chapter I Pages

Anatomical conditions — General considerations with regard to anastomosis — Materials required for an intestinal anastomosis — Needles — Sutures — Clamps — Varieties of suture : interrupted and continuous - - - - - 1-20

Chapter II

Method of closing an incised wound of bowel — The choice between a lateral and end to-end anastomosis — Lateral anastomosis by sutures alone — The management of the mesentery— Occlusion of the intestine — Halsted's operation — Lateral anastomosis by continuous suture - - 21-35

Chapter III

End-to-end anastomosis by sutures — M aunsell's method — Metho by two rows of interrupted sutures — Double row of continuous sutures — Anastomosis by sutures and apparatus — O'Hara's clamp forceps — Laplace's forceps — Halsted's rubber bag — Mayo Robson's bobbin — Allingham's bobbin — Landerer's potato bobbin — Murphy's button - - - - 36-62

Chapter IV

Operations on the stomach — Suture of gastric ulcer — Gastro-enterostomy : anterior and posterior — * Vicious circle * — Comparison between different methods — Pyloroplasty — Pylorectomy ._-..- 63-80

CHAPTER V Operations on large and small intestines — Ileo-colostomy

Enterostomy — Colotomy - - - - 81-89

vii viii Contents

Chapter VI Pages

Operations on gangrenous bowel caused by hernia and internal strangulation — Operative treatment of intussusception — Treatment of artificial anus or faecal fistula : (i) Small intestine ; (2) large intestine— Comparison of various methods — Treatment of cancer of the colon - - - 90-108

CHAPTER X Treatment after abdominal operations - - - - 144-163 LIST OF ILLUSTRATIONS

FIG. PAGE

1. Diagram of the Coats of the Small Intestine - - - 2

2. Cal)rx-Eyed Needles ------ 7

3. Doyen's Clamp --..._ g

5. Elastic I^igature Clamp - - - - 10

6. Maunsell's Sponge Clamp - - - - -11

7. Lembert's Suture - - - - - 12

8. Czerny Suture - - - - - -13

9. Wolfer's Suture - - - - - - 13

10. Joubert's Suture - - - - 14

11. Halsted's Suture - - - - - - 15

12. Continuous Lembert Suture - - - - - 16

13. Continuous Glover's Sutujre - - - - 17

14. Continuous Cushing's Suture - - - - - 17

15. Continuous Mattress Suture - - - - - 18

17. Purse-string Suture - - - - - - 19

18. Closure of Incision in Bowel Wall, First Stage - - 21

20. Method of Closing Wound with Loss of Substance - - 22

21. Ditto, Completed - - - - - - 23

22. The Method of Applying Two Pieces of Bowel in Short-

Circuiting - - - - - - -26

23. The Method of Applying Two Pieces of Bowel after Enter-

24. Occlusion of Intestine - - - - - 27

26. Ditto, as seen from above - - - - - 29

27. Halsted's Method of Lateral Anastomosis - - - 30

29. Ditto, Third Stage - - - - - - 31

30. Ditto, Final Stage - - - - - - 32

ix

List of Illustrations

31. Lateral Anastomosis by Double Continuous Sutures- - 33

33. Ditto, Third Stage ------ 34

34. Management of the Mesentery - - - - 3^

35. Ditto, Completed - - - - - -37

36. Showing Oblique Section of the Bowel in End-to-End Anas-

37. MaunseU's Method of End-to-End Anastomosis - - 39

41. Ditto, Operation, Completed - - - - - 42

42. End-to-End Anastomosis by Interrupted Sutures - - 43

44. Ditto, Third Stage - - - - 44

45. Ditto, Final Stage - - - - - - 45

46. Ditto, by Continuous Suture - - - - - 46

47. Ditto, by Continuous Suture, Stitch through Mucous Mem-

48. O* Harass Clamp Forceps - - - - - 48

49. Method of Performing End-to-End Anastomosis by Halsted's

Suture over O'Hara's Forceps - - - - 49

50. Laplace's Forceps - - - - - 50

51. Halsted's Air CyHnder - - - - - 52

52. Halsted's Air CyUnder in Position - - - - 53

53. Mayo Robson's Bone Bobbin - - - - - 54

54. Ditto, in Position - - - - - - 55

55. Ditto, the Suture Completed - - - - - 56

56. AlUngham's Bone Bobbin - - - - - 57

57. Ditto, in Position - - - - - - 58

58. Landerer's Potato Bobbin - - - - - 58

59. Murphy's Button - - - - - - 59

60. Purse-string Suture round Intestine - - - - 60

61. Method of holding Button - - - - - 60

62. Murphy's Button in Position, Mesenteric Stitch - - 61

63. Closure of Ruptured Gastric Ulcer - - - - 64

64. Ditto, Second Method - - - - - 64

65. Finding the First Part of the Jejunum - - - 66

66. Anterior Gastro-Jejunostomy by Halsted's Method - - 67

67. Anterior Gastro-Enterostomy - - - - 68

69. Posterior Gastro-Enterostomy - - - - 70

70. Method of Performing Entero- Anastomosis - - - 72

71. Gastro-Enterostomy by Roux's Method - - -72

72. Ditto, Completed - - - - - - 73

List of Illustrations xi

FIG. PAGE

73. Pyloroplasty - - - - - - -77

74. Pylorectomy combined with Gastro-Enterostomy - - 79

75. Ileo-Sigmoidostomy - - - - - 82

77. Method of Introduction of Paul's Tube in Enterostomy - 85

78. Colotomy, First Stage - - - - - 87

80. Method of Excising an Intussusception - - - 95

81. Ditto, the Operation Completed - - - - 96

82. Dupuytren's Enterotome - - - - - 99

83. Ditto, appUed Dividing Spur - - - - - 100

84. Incision through Parietes in Appendectomy - - - 114

85. Division of Meso- Appendix - - - -US

86. Cuff of Appendix Dissected Back - - - 1 1 5 ^7, Invagination of Stump of Appendix - - - 116

88. Invaginated Stump seen on Section - - - - 117

89. Incision through Rectus Sheath - - - - 1 20

90. Edge of Peritoneum held up for Passage of Peritoneal

91. Section of Wound in Rectus Sheath after Closure - - 123

Section I GENERAL CONSIDERATIONS

I. Anatomical Conditions! — ^The small intestine has four important coats, as shown in Fig. i. They vary in thickness and in toughness in different parts of the bowel.

1. The peritoneal coat does not completely surround the gut in any part of the intestine ; there is always the portion of the circumference of the bowel at the attachment of the mesentery which is uncovered with peritoneum. The extent of this uncovered area varies in different parts. It is smallest in the ileum, where only about one-tenth of the circumference is uncovered. In the duodenum, ascending and descending colons, the portion which is not covered with peritoneum is nearly one-half of the circumference, and in the transverse colon and sigmoid the uncovered area is about one-fifth of the whole.

2. The muscular layer is the thickest coat of the bowel, and consists of longitudinal and circular fibres. Although of considerable thickness, it is not, however, of great strength, and sutures which take a hold of this coat only will readily cut out. The thickness of the coat varies with the contraction or dilatation of the gut, being many times smaller in atonic distension than in normal contraction.

3. The submucous coat is not of great thickness, but it is composed of very tough fibrous tissue, and only a few fibres of this coat have a greater resisting power than

Fig. I. — The Coats of the Ileum. (L. Mark.)

P, peritoneal coat ; M, muscular coat ; SM, submucous coat ; MM, mucous membrane ; A, artery of mesentery.

the whole of the serous and muscular coats. It is essential, in order to secure firm union, that a portion of this coat be included in each suture.

4. The mucous membrane varies much in thickness, being thickest in the jejunum, and thinnest in the lower part of the ileum and in the large intestine. The coat is very friable, and sutures passed through this coat alone will easily cut out.

The fact that the valvulae conniventes are present in

General Considerations 3

large numbers in the jejunum, and are absent in the lower part of the ileum, and can be easily felt through the bowel, gives us an easy way of distinguishing a coil of jejunimi from one of the ileum.

To sum up, the mucous coat is the most friable, the submucous coat is the toughest, the .muscular coat is the thickest, but not the strongest, and the peritoneal coat is incomplete.

The peritoneal coat, however, is of the very greatest importance, since the earliest and firmest adhesions between portions of intestine are formed between adjacent peritoneal coats. It is, therefore, essential that portions of intestines which are covered with peritoneum should be selected for an anastomosis.

In the small intestine the two sides of the mesentery are sufficiently close together that when the adjacent portions are in contact they will complete the peritoneal investment, and so end-to-end anastomosis presents no great difficulty. In the ascending and descending colon, however, the absence of peritoneal covering over one-half the circumference makes an end-to-end anastomosis a hazardous procedure.

Generally speaking, the part of the intestinal wall which unites most readily is the convex border, or that portion exactly opposite to the mesenteric attachment ; this is the point selected for incision of the gut in the case of extraction of a foreign body such as a gall-stone, or for th§ temporary relief of obstruction. This also is the point selected for the line of union in performing a lateral anastomosis, and so it follows that a lateral anastomosis is a very safe method of uniting intestines.

II. Another point of importance is that the anastomosis should be made between equally movable portions of gut, and it is undesirable that a movable piece of gut should be united to a fixed one, since the intestinal contractions in the movable portion of gut will cause this portion to pull upon the stitches when united to a fixed part. Thus the ileum should not be connected to the ascending or descending colon, but when it is necessary to unite it to a portion of the large intestine the union should be made with the transverse colon or the sigmoid. In the same way the only parts of the large intestine which should be united to each other are the transverse colon or the sigmoid. Again, the fixed duodenum should not be united to the movable stomach, but the movable jejunum should be employed in its place.

III. When the knots of sutures are left on the peritoneal surface of the gut, it is essential that the suture should not penetrate through all the coats of the gut, since there would then be a probability of infection of the peritoneum by absorption from the intestinal tract- It is quite a question whether the mere fact of the silk becoming infected by absorption of intestinal contents will lead to any bad effect ; the real danger lies in the fact that when once the suture has become infected it will have to separate, and it will do this in the direction of least resistance. When the knot is inside the bowel a little irritation is set up just round the suture, which effectually shuts off the peritoneal cavity, and then sufficient inflammation and ulceration are excited to cast off the suture within the cavity of the bowel, a very small tract being left after it has been discharged ; this, however, is sealed by peritoneal adhesion, and so gives rise to no trouble.

When, however, the knot is outside, and the suture has become infected, it will have to separate in the

General Considerations 5

direction of least resistance, which will be the cavity of the gut, since on the outside there is the general intra-abdominal pressure. As the knot has to traverse the whole thickness of the bowel coats, a considerable amount of ulceration is necessary to allow it to pass within the lumen, and the tract left is of a considerable size, and it is thus that extravasation may. occur.

When, therefore, sutures pass through all the coats, the knot should be placed inside the bowel, and even if no supporting row of sutures be inserted, this will not lead to infection and extravasation.

IV. It is most essential to tie each stitch as tightly as possible, since a stitch which is tied sufficiently tightly when the gut is collapsed will become loose when the gut is distended, the reason being that when the bowel is collapsed the muscular coat is much thicker than when it is distended, all its coats being then thinned. It must be remembered that every injury to the intestine wiU produce some temporary paralysis, which is accompanied by dilatation of the part.

V. The anastomoses should, when possible, be done outside the abdominal cavity, so as to lessen the risk of infection ; this is not difficult, if only movable portions of the gut be united.

VI. A surgeon should not be dependent upon any special apparatus for the performance of an anastomosis, since the necessity for the performance will often arise in the course of some other operation when the special apparatus is not at hand. It is therefore desirable that he should first be perfect in some simple suture, and after this he can use any apparatus if he desires it.

VII. Other things being equal, the patient's chances of recovery are greatly enhanced by rapid operating, and this can only be obtained by practice.

VIII. It is almost unnecessary to impress upon the surgeon the necessity of counting all instruments and sponges employed before and after an operation.

Section II MATERIALS REQUIRED FOR AN INTESTINAL ANASTOMOSIS

The ordinary instruments required are a scalpel, eighteen or twenty-four small Spencer WeUs forceps, dissecting forceps (two pairs), two large abdominal retractors, one small retractor, a pair of blunt hooks (button-hooks do very well in an emergency), a needleholder to take curved needles (as made by Krohne and Seesman), ordinary surgical needles for closing skin incision, fine silk for ligatures, silkworm gut for the wound, various sponges, round or flat, or sterilized wool mops wrapped in gauze.

The special instruments required are (i) intestinal needles, (2) clamps, (3) material for suture. It is most important to have proper needles, since, if ordinary surgical needles with sharp sides be employed, there is a great risk of the delicate coats of the intestine being cut through if the needle be held at all slantingly. Both straight and curved needles should be at hand ; the straight needles are ordinary sewing-needles, which can be obtained from any haberdasher, and the most convenient size is No. 8. It is convenient to have rather a longer needle than the sewing-needle, and such a one is called a straw needle. In order to use a small-size needle, I recommend that the open-ended or calyx-eyed needle should be obtained ; they save an infinite amount of trouble in threading — in fact, until I employed them, I used to find it impossible to thread No. 8 needles with

General Considerations 7

wet silk, and I had to sterilize the silk and needles together after threading — an undesirable proceeding, since the loop of silk within the needle is liable to become rotten by development of a little rust in the eye of the needle during boiling. Again, if a needle comes unthreaded in a continuous suture, it is instantly rethreaded in the case of a calyx-eyed needle. These needles have a spring eye, as shown in Fig. 2. They are threaded by simply passing a piece of silk over the end.

Straight needles are most useful in picking up the

Fig. 2. — Straight and Curved Intestinal Needles, with ' Calyx * Eye (Enlarged Sketch of Calyx Eye). (Down Bros.)

submucous coat, since they are driven in with the pulp of the finger, and when used in this way it is easy to recognise the resistance of the different coats.

Curved needles, which must also be made round, are useful for continuous sutures, especially when an anastomosis is performed within the abdominal cavity, when straight needles could not be used so easily. I strongly advise those made with calyx eyes to be used, since it is practically impossible to thread the intestinal needles supplied by some instrument makers. The ordinary full-curved needle is the best shape, and the semicircular ones which are often supplied are not so easily handled. I should just like to utter a warning against the use of Hagedorn's needle. The cutting edge of the needle and the large round eye make it very unsuitable for intestinal work.

Clamps

I do not propose to describe all the forms of clamps which have been recommended for intestinal work ; I shall only refer to those which I use myself. One of the best is Doyen's (Fig. 3). You will notice that the

Fig. 3. — Doyen's Intestinal Clamp. (Down Bros.)

blades are made with fine grooves, and are bowed so that their tips meet before the centre. In this way it is easy to regulate the amount of pressure on the gut when it is applied ; it is unnecessary to strangulate the gut, the chief use of a clamp being to prevent the passage of any intestinal contents, and so it need be only lightly applied. Two of these clamps are a useful addition to the equipment of a surgeon.

The other clamp which I employ and recommend to you is the one introduced by Mr. Arbuthnot Lane, and bears his name. It consists (Fig. 4) of a steel rod, having a blimt point at one end and a notch at its other end, to which an elastic ring is attached ; a small cap with a

Clamps 9

notch fits on the blunt point, and when the cap is in position the elastic ring is stretched over the whole. It is applied by passing the blunt point through the mesentery close to the gut, and then applying the small cap with the elastic band attached, so that the gut is compressed between the elastic band and the rod. It is very simple and inexpensive, and two of them are useful. The application of this clamp is seen in Fig. 42.

Still, however, the most important thing is to be able to clamp the gut without any special apparatus, and the following two methods are very simple and efficacious :

I. A fine pair of Spencer Wells forceps is passed

BROS LONDON

Fig. 4. — Lane's Intestinal Clamp. (Down Bros.)

through the mesentery close to the gut, and about 6 inches of a small-size rubber tubing (sterilized) is drawn through the hole, and the two ends of the tubing tied lightly together over the gut, with just sufficient force to obliterate the canal ; the knot, which is a single one, is prevented from slipping by applying a pair of Spencer WeUs forceps as shown in Fig. 5. The constriction is easily removed by taking off the forceps. I have used this method in ■ a number of cases, and have found it absolutely satisfactory. The constricting tubing cannot slip, as it is passed through the mesentery.

2. Maunsell's method, which consists of a piece of sponge and a safety-pin, both of which are easily sterilO lized by boiling. The safety-pin is passed first through the piece of sponge, then through the mesentery close to the bowel, and then through the sponge again, and fastened ; in this way the bowel is compressed between the safety-pin and the sponge. This is shown in Fig. 6. The piece of sponge should be the same length as the safety-pin. It is a

Fig. 5. — Method of Clamping Intestine by Elastic Ligatures.

(L. Mark.)

very convenient method, and is very efficacious. I do not like it so much as the method before described.

One word as to the application of clamps. They should not be applied for a longer period than is necessary ; they should not, therefore, be applied until the bowel is about to be opened. The first row of sutures should

Clamps 1 1

be inserted before the application, and in Halsted's method the whole of the sutures are inserted before it is necessary to use a clamp. Secondly, they should be applied at some distance from the part to be sutured, at least 2 inches away. There are two reasons for this — (i) that the vessels close to the anastomoses should not be damaged by the clamp, and (2) that the walls of the gut should not be dragged out of position by the clamp.

Thirdly, they should be taken off as soon as possible, and in cases where the anastomosis is effected by a

Fig. 6. — Maunsell's Sponge and Safety-pin Clamp.

I, Stricture of intestine ; 2, sponge ; 3, safety-pin passed through mesentery.

double row of sutures the clamp may usually be removed with safety when the first row has been completed. Lastly, there is no clamp so good as an assistant's fingers ; but if the operation is prolonged this is apt to be trying for him. In Halsted's anastomosis I do not think a clamp is necessary, since the sutures are all passed before the bowel is opened, and as the anastomosis is done outside the abdominal cavity, any slight escape of intestinal contents can be wiped up, and there is no fear of any finding its way into the peritoneal cavity.

Section III THE VARIETIES OF SUTURE

I. Interrupted. — i. The best -known suture is the Lembert suture, which aims at picking up the peritoneal and fibrous coats alone {vide Fig. 7). The essential part

Fig. 7. — Lembert's Suture. (L. Mark.)

of the stitch is that the needle is inserted about ^ inch from the cut edge, and brought out at yV inch from the edge, so as to produce some inversion of the edge of the gut and insure the apposition of the peritoneal surfaces. It is not, however, a very strong stitch, and is very liable to cut out ; this can easily be verified by pulling on it.

2. The Czemy stitch is one which is passed through the mucous membrane alone, and the knot is tied on the in-

Varieties of Suture

Fig. 8. — Czerny-Lembrrt Suture. (L. Mark.)

The Czerny stitch is the lower one, passing through the mucous mem

brane alone. Above this is an ordinary Lembert stitch.

Fig. 9. — Wolfer's Suture.

I, Lembert's suture passed through serous, muscular, and submucous coats ; 2, modified Czerny suture passed through all the coats, and tied inside the bowel ; 3, serous coat ; 4, muscular coat ; 5, submucous coat ; 6, mucous membrane.

side of this coat ; this stitch is shown in Fig. 8, and is only used in combination with Lembert's stitches.

3. In Wolfer's method, the first row of stitches passes through all the coats of the bowel, and the knots are tied inside as far as possible ; at any rate, each stitch is passed from mucous membrane to serous of one edge, and from serous membrane to mucous of the other edge. The method is completed by a row of Lembert's sutures. This is an excellent method, and gives a strong support.

Fig. 10. — Joubert's Method. (L. Mark.)

4. Joubert's stitch, as shown in Fig. 10, aims at producing an invagination of one portion of the intestine into the other, but it cannot be recommended, since it is passed through all the coats of the bowel and has its knot outside. Infection is therefore probable.

5. Halsted's Method. — In this method each stitch is made to pick up some of the fibres of the submucous coat, since this coat possesses the most tough fibrous tissue of all the others. It is easy to distinguish the resistance of this coat by passing a needle with steady pressure verti-

Varieties of Suture cally into the gut, when it will be found that a considerable steady pressure is needed before the gut is perforated ; of course, a jerk will perforate it at once. If the needle is pressed steadily towards the lumen, and when the resistance is felt it be lateralized, and pushed on so as to emerge from the serous coat again, the point will pick up some fibres of the submucous coat. Halsted employs a double stitch, called a mattress suture, so as to bring a larger amount of serous surface in apposition. The

Fig. II. — Halsted's Mattress Suture. (L. Mark.)

needle is made to enter i inch and to come out at yV inch from the edge, then to enter yV inch from and to emerge I inch from the opposite edge ; it is then reinserted ^ inch away from the point of exit, and passed in the same way through both edges. Each stitch should be |^ inch apart, and the row should be parallel and equidistant (see Fig. II). In order to insure this, it is best to pass the whole row of sutures and clamp their ends before tying any. This stitch is the ideal one, since it does not perforate the mucous membrane, and yet it is absolutely strong, and no extravasation can take place. It is the one which I employ on practically all occasions.

II. Continuous. — ^These can be classified according to the coats of the bowel which are included in them, or according to their shape.

I. The simplest form is the continuous Lembert, or Dupuytren's suture, which is used in most cases where two rows of sutures are inserted. It is inserted in the same way as the simple Lembert, and care should be taken that the needle is made to enter points in each edge opposite to each other. Fig. 12 shows this suture. The suture is commenced by passing an ordinary Lembert stitch, which

Fig. 12. — Continuous Lembert or Dupuytren. (L. Mark.)

is tied ; the end of the silk to which the needle is attached is then used for the continuous suture ; it is finished off by tying it to one of the ends of an ordinary Lembert suture which has been inserted just beyond the termination of the continuous suture, or it may be finished off by not pulling the short end of the silk through the last stitch-holes, and then tying this short end to the loop on which the needle is threaded. It is essential, in passing the continuous suture, (i) to pull each stitch tight after passing it, and, (2) in order to prevent undue puckering when putting in the stitch, to oversew the suture every third or fourth stitch ; this is shown in Fig. 13.