A System of Operative Surgery, Volume IV (of 4)

When the abdomen is opened for the purpose of removing a diseased viscus, the operation receives a specific name, such as nephrectomy, gastrectomy, splenectomy, and so forth. In many instances the abdomen is occupied by a tumour which defies the skill of the surgeon to localize to any particular organ until it is exposed to view through an incision; it is usual to apply the term c?liotomy to an operation of this kind, and it merely implies that the belly is opened by a cut.

C?liotomy is a useful expression, because many abnormal conditions arise in the abdomen which require treatment through an incision in its walls which do not lend themselves to an expressive term, for example, the removal of omental cysts, the evacuation of pus, blood, or the removal of foreign bodies, &c. It is true that a c?liotomy performed on an uncertain diagnosis may become a colectomy, ovariotomy, hysterectomy, &c., and the preliminary step to the performance of the operations to be described in this section is an abdominal incision, or c?liotomy. For whatever purpose a c?liotomy is required in the treatment of diseases of the female pelvic organs, the preparation of the patient and the initial steps are alike; it will therefore be convenient to describe the manner of carrying them out.

The preparation of the patient. It rarely happens that an operation is so urgent as to leave little time for a thorough preparation of the patient. It is desirable that the preliminaries should occupy two days at least. During this time the patient is kept in bed and the bowels are freely evacuated, either by calomel at night, with a saline draught in the morning, or by an ounce of castor oil.

On the morning of the operation the large bowel is thoroughly emptied by a soap and water enema, care being taken to use soft soap, to avoid producing a pimply eruption known as the 'enema rash'.

It is well known that injuries to the abdominal organs, whether by accident or in the course of a surgical operation, are liable to be followed by septic parotitis. Recent writers attribute this complication to microbic infection of the ducts of the salivary glands (see p. 99); its occurrence may be avoided by including careful cleaning of the teeth among the preliminaries advisable for an abdominal operation. It is such a simple and comfortable ordinance that there is no reason for not following it.

The preparation of the skin needs to be very thoroughly carried out. After a warm bath the hair is shaved from the abdomen, pubes and vulva, and the skin is well washed with warm soapy water and swathed in gauze compresses wrung out of a solution of perchloride of mercury, 1 in 5,000. These compresses remain for twelve hours. The abdomen is again washed, and a second compress is applied which remains on until the operation.

Occasionally patients object to have the abdomen and pubes shaved. In such cases the hair can be easily removed by a depilatory. I have found a powder prepared according to the following formula useful:-

Sodium monosulphide, 1 part; calcium oxide, 1 part; starch, 2 parts; sufficient water is added to make a stiff paste, which is spread over the parts. After five minutes it is washed off by means of a dab of cotton-wool and the skin freely washed with warm water. This preparation is only efficacious when freshly prepared.

The washing and application of compresses require care on the part of the nurse, for some patients have skin so tender that it is easily blistered, and a crop of small pustules is a source of inconvenience, and leads to stitch-abscesses. In certain cases over-preparation may be worse than no preparation.

When patients are advanced in years it is extremely necessary to protect them from being chilled by undue exposure. It is well to clothe their lower limbs in warm flannel garments or drawers made out of Gamgee tissue. No open doors or windows should be permitted; though in summer this is comfortable to the surgeon it may be disastrous to the patient. In winter the temperature of an operating-room should not be below 65°F. In this way ether pneumonia is best avoided.

In operations, such as o?phorectomy, ovariotomy and hysterectomy, it is the rule not to operate during menstruation; experience has taught me that operations performed during this period are not followed by evil or untoward consequences, and for many years I have disregarded it.

Immediately before the patient is placed on the table the bladder should be emptied naturally, or by means of a sterilized glass catheter.

In all pelvic operations it is a great advantage to employ nurses who have had a special training in 'abdominal nursing'.

Basins and dishes. All receptacles such as basins, pots, instrument dishes and the like should be boiled. Mere rinsing or washing in warm water is insufficient.

Instruments. These should be constructed of metal throughout, as this enables them to be thoroughly sterilized by boiling. Needles and scalpels may be enclosed in perforated metal boxes. Forceps and the handles of scalpels are nickelled, and this keeps them bright. The following instruments are necessary: Scalpel, twelve h?mostatic forceps, dissecting forceps, two fenestrated forceps which are also useful as sponge-holders, a volsella, six curved needles of various sizes, two straight needles, silks of various thickness, and six dabs.

The surgeon should make a practice of employing a definite number of instruments and dabs for all occasions, as it will save him much anxiety in counting them at the end of the operation.

During the operation the instruments and silks are immersed straight from the sterilizer in warm sterilized water.

Suture and ligature material. The most useful material at present employed in pelvic surgery is silk. This material has a wide range of usefulness, as it is employed to secure pedicles, for the ligature of blood-vessels, and for sutures; it can be obtained of any thickness, and is easily sterilized by boiling without impairing its strength. In abdominal surgery there are four useful sizes, No. 1, 2, 4, and 6, of the plaited variety of silk. The thread is wound on a glass spool and boiled for one hour immediately before use. If any silk is left over from the operation it may be reboiled once or twice without impairing its strength. (The fate of silk ligatures is discussed on p. 117.) Many surgeons employ catgut and hold it in high esteem. I regard it as an unsatisfactory and dangerous material; moreover it cannot be boiled, which is the simplest and safest method of making ligatures sterile.

Dabs. Nothing is so convenient for removing blood from a wound as sponges; their absorbent property and softness are excellent, but they are difficult to sterilize; therefore they are highly dangerous, and on this account should be banished from surgery. An excellent substitute is absorbent cotton-wool enclosed in gauze (Gamgee tissue). This material can be cut to any size or folded into any shape, and is easily sterilized by heat, or by boiling, without damage to its absorbent properties.

For a c?liotomy six dabs are prepared of various sizes, according to the nature of the case. These are boiled for one hour and then immersed in sterilized warm water and washed from time to time in the course of the operation.

I always employ six dabs, then there is no difficulty at the end of the operation concerning their number. The dabs at the completion of the operation are destroyed.

Many serious consequences have arisen from dabs and instruments accidentally left in the peritoneal cavity after pelvic operations. This subject is considered on p. 105.

The operator should remember that his responsibility in this matter is determined by a decision in a Court of Law.

The employment of dry gauze dabs in abdominal operations is objectionable because it is harsh and irritating to the peritoneum and leads to the formation of adhesions.

Gloves. Increasing experience proves that gloves are most valuable in securing freedom from sepsis. It is a very important matter that the surgeon, the assistant, and the nurses who help at the operation should wear rubber gloves boiled immediately before the operation for ten minutes.

The wearing of gloves diminishes the mortality of the operation, and minimizes its unpleasant and often dangerous sequel?, such as suppuration around sutures, septic emboli, tympanites, and the like. Care must be taken to impress upon all who take part in an operation that it is as essential to thoroughly wash and disinfect the hands before inserting them in gloves as when no gloves are worn. It is also necessary to warn nurses that the smallest hole in a glove renders it useless.

To the operator thorough disinfection of the hands is of the highest importance, for he may puncture or tear the gloves during the operation; or a difficulty may arise in the course of it which will render it advantageous for him to remove one or both gloves to overcome it. It is with me a rule that if in the course of an operation it is necessary to remove the gloves, I resume them for the final stages, and particularly for the insertion of the sutures. The use of rubber gloves marks a most important advance in operative surgery.

The operating table. In many cases of c?liotomy a table such as is employed for the ordinary operations of surgery answers very well, but for hysterectomy, o?phorectomy, and similar procedures it is a great convenience to use a table on which the patient can be placed in the Trendelenburg position, that is, with the pelvis raised, and the head and shoulders lowered: this allows the intestines to fall towards the diaphragm and leave the pelvis unencumbered. There are many varieties of tables employed for this purpose. As these tables are made of metal, it is necessary before the table is tilted to fix the patient's arms parallel with her trunk, otherwise they fall across the edge of the table, and in some instances a troublesome paralysis of the muscles of the upper limb has been the consequence.

It is worth while pointing out that most of the examples have happened in the course of long operations (see Post-an?sthetic paralysis, p. 95).

An?sthesia. The majority of surgeons employ a general an?sthetic, such as ether, chloroform, or a mixture of chloroform and ether, in pelvic operations. The most usual practice in London is to render the patient unconscious with nitrous oxide gas and maintain the an?sthesia with ether. It is a method which has given me the greatest satisfaction. As a rule, it is wise whenever possible to employ an experienced an?sthetist and trust to his judgment in regard to the selection of the an?sthetic.

In exceptional cases pelvic operations such as ovariotomy and hysteropexy have been successfully performed with the aid of intradural injections of a solution of eucaine, novocaine, or stovaine.

The incision. The operation-area is isolated by sterilized towels and the pelvis well tilted and so arranged as to face a good light. When the patient is completely unconscious, the operator (standing usually on the right side with the assistant opposite him) freely incises the wall of the abdomen in the middle line between the umbilicus and the pubes (this incision is conveniently termed the median subumbilical incision; its length varies with the necessities of the case, but is usually 7 to 10 centimetres). The first cut generally exposes the aponeurotic sheath of the rectus; any vessels that bleed freely require seizing with h?mostatic forceps. The linea alba is then divided, but as it is very narrow in this situation, the sheath of the right or left rectus muscle is usually opened. Keeping in the middle line, the posterior layer of the sheath is divided and the subperitoneal fat (which sometimes resembles omentum) is reached; in thin subjects this is so small in amount that it is scarcely recognizable, and the peritoneum is at once exposed, and, as a rule, the urachus comes into view. In order to incise the peritoneum without damaging the tumour, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall; the surgeon then introduces his finger, and divides the peritoneum to an extent equal to the incision in the skin.

It is important to remember that the bladder is sometimes pushed upward by tumours, and lies in the subperitoneal tissue above the pubes; it is then liable to be cut.

On entering the peritoneal cavity, the surgeon introduces his hand, and proceeds to ascertain the nature of any morbid condition that he sees or feels, or he evacuates any free fluid, blood, or pus which may be present. Occasionally he finds that attempts to remove a tumour would be futile or end in immediate disaster to the patient; then he desists and closes the wound, and the procedure is classed as an exploratory c?liotomy. Should a removable tumour, such as an ovarian cyst, an echinococcus colony in the omentum, or the like be found, it is removed.

Before suturing the incision, the surgeon usually spreads the omentum over the small intestine; occasionally he will be surprised to find this structure, even in well-nourished women, represented by a mere fringe of fatty tissue attached to the lower border of the transverse colon.

The recesses of the pelvis are then carefully mopped in order to remove fluid, blood, or pus; the dabs and instruments are counted, and preparations made to suture the incision.

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 c?cum 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 gyn?cological 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 c?liotomies; 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 c?liotomy 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).

In studying the details of such operations as ovariotomy and hysterectomy from books, it should be remembered that it is merely the principles that can be explained. There are so many details in every operation that can only be learned from watching, or, what is far better, assisting a skilful and experienced surgeon in their performance. This is true of all forms of surgical procedure. No man can become a navigator without going to sea, however thoroughly he masters the principles of seamanship from books, so no surgeon can acquire the art of operating from merely reading descriptions of surgical operations. If a surgeon can bring to bear upon abdominal gyn?cological operations, in addition to mere surgical dexterity, a competent knowledge of the pathology of the organs, he will find it of the greatest assistance. I would warn him particularly to take little heed of the sneers of those eminently practical surgeons who affect to despise pathology.

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