Introduction and Background

CARE OF PATIENTS UNDERGOING GYNECOLOGIC and ABDOMINAL PROCEDURES BEFORE, DURING, AND AFTER OPERATION BY E. E. MONTGOMERY, A.M.,M.D.,LL.D.,F.A.C.S. Professor of Gynecology in Jefferson Medical College; Gynecologist to Jefferson and St. Joseph's Hospitals; Consulting Surgeon to the Philadelphia Lying-in Hospital, the Jewish Hospital, the Kensington Hospital for Women, and the American Oncologic Hospital ILLUSTRATED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1916 aS 6E*X MED. fay < MAY 31 1917 a 4 a € y Copyright, r9x6, by W. B. Saunders Company PRINTED IM AMERICA PRESS OF W. 8. SAUNDERS COMPANY PHILADELPHIA TO THE MANY LOYAL AND DEVOTED WOMEN WHOSE “FAITHFUL SERVICE HAS MADE GOOD SURGERY POSSIBLE THIS BOOK IS RESPECTFULLY DEDICATED. PREFACE Every surgeon, in preparing for an unusual operation, has found it difficult to decide just what instruments and materials should be selected. To the novice in the operating room, nurse, or intern every operation is an unusual one, and with- out special instruction in preparation for various operations important instruments and articles will be overlooked. The surgeon, too, harassed with the care of many patients, will not infrequently find that in his selection he has omitted some things which would have greatly expedited his work. While convalescing from an operation last summer the writer decided to prepare for his assistants some typewritten instructions which, as the work progressed, he found it neces- sary to extend, until this little book is its outgrowth. He has endeavored to present a chart which, if intelligently followed, will greatly accelerate the work of the surgeon, add to the comfort of his patients, and redound to the. credit of his assistants. His own experience assures him that this book will prove valuable to the young gynecologist by making easy his early steps alone in the field of pelvic and abdominal surgery. He takes this opportunity to express his appreciation of the courtesy and generous co-operation of the publishers; to 7 8 PREFACE thank Mr. J. V. Alteneder and Miss S. L. Clark for their work in the preparation of the illustrations; Messrs. Charles Lentz and Sons and Miss Clara Melville for the loan of instruments, and Miss Nellie M. Gandley for the work of transcribing. If this book, as it passes from his hands, by lessening the anxiety of the surgeon, promotes better work, facilitates the labor of nurses and interns, but, above all, adds to the comfort and satisfaction of the patients, the author will feel well re- paid for his efforts. . E. E. Montcomery. 1426 SpRUCE Sr., PHILADELPHIA, Pa, September, 1916. CONTENTS GENERAL PART On Admission. . Preparation of the Field for Operation. The Incision....... Closure of the Wound Dressings. . Clinic Work. Care of Patient During Operation. ing Hemorthage, External and Internal. ‘Tympanites. . : Abdominal Pain and Tenderness Peritonitis. . Sepsis. Phlebitis. ABDOMINAL AND PELVIC OPERATIONS Shortening Ligamentsijjsics0 03 csee ae Pyensewenece vies sow TeT ew ED Salpingectomy—Salpingo-obphorectomiy.. Ovariotomy. . Hysterectomy—Panhysterectomy—Subtotal Hysterectomy. Intestinal Resection and Anastomosis. Gastric Operations. Gastropexy.. Gastrotomy. Gastro-enterostomy. 10 CONTENTS PAGE Gall-bladder Operations. 907 ‘The Spleen......... . 103 Operation Upon the Kidney. . 105 VAGINAL OPERATIONS Dilatation and Curetment. . 116 Trachelorrhaphy. . 19 Amputation of Cervi + 133 Anterior Colporrhaphy. . . . 128 Vesicovaginal Interposition of Uterus; Watkins’ Operatio + 130 Vaginal Hysterectomy... 132 Perineorthaphy; Posterior Colporrhaphy; Rectovaginal Interposition of LevatorAni Muscles:esscisyevid dsp tdeatsogueadivecveunesass 138 ON M EDR e) OD « MAY 31 1917 Lipriss eM 4 CARE OF GYNECOLOGIC PATIENTS GENERAL PART ON ADMISSION OF THE PATIENT Nurse’s Duties.—On admission of a patient, the nurse should record the temperature, pulse, and frequency of res- piration; secure a specimen of urine for examination, and, if her condition is in any way unsatisfactory, should notify the intern at once. Intern’s Duties.—Every operative patient should have the urine examined, an ordinary blood-count made, and her blood-pressure taken. A careful history should be written, and on his visit the attention of the visiting surgeon directed to her. A supranormal temperature, anemia, or the appar- ent appearance of recent hemorrhage should indicate a com- plete blood-count. If she has a vaginal discharge, a smear should be taken for examination and cultures made. In septic conditions it is wise to order cultures made from the blood and institute measures to secure vaccines. When the date for operation has been decided, the pa- tient should be ordered a purgative for the morning preced- ing (the best, Ol. ricini, f3ij) and a soap-and-water enema for the night before. The diet for the day before should 1 12 CARE OF GYNECOLOGIC PATIENTS have as little waste material as possible and only hot water on the morning of operation, unless it is to take place late in the day, when the patient may be given a little bouillon, clear soup, or a cup of tea or coffee without milk. PREPARATION OF THE FIELD FOR OPERATION The field for operation should be prepared by the re- moval of the hair, either by shaving or with a depilatory. The latter is less objectionable in that the skin is uninjured and no opportunity is thus afforded for skin infection. The following prescription forms a very satisfactory depilatory: Calcii caustici pulveri. Sodii sulphid. . Amyli.. - 10.0 3.0 - 10.0 Pulverize separately, mix, and keep in a bottle dry. When desired to be used, mix with enough water to make a paste and spread on the surface about } inch thick with a wooden spoon or glass spatula. When applied over the vulva the mucous surface should be previously painted with some sterile oil as a protection. The entire abdominal surface should be deprived of hair, the surface bathed with soap and hot water and afterward with alcohol. After the surface has had time to dry it should be painted with an alcoholic solution (3.5 per cent.) of iodin and have a sterile dressing kept in place with a bandage. This painting should be repeated the evening before the operation and again after the patient is brought to the oper- ating-table. After the last painting has become dry, the PREPARATION OF THE FIELD FOR OPERATION 13 entire surface should be sponged with a gauze pad wet with alcohol to remove the superfluous iodin and prevent its in- juring any coils of intestine which may escape and come in contact with the skin surface. This precaution may save the patient from desquamation of the intestinal endothe- lium which would most certainly cause subsequent adhe- sions and their unfortunate sequele. Should the patient suffer from a condition which requires immediate attention, and the requisite time for preparation cannot be taken, the abdomen should be shaved, then be washed first with gasoline, subsequently painted with iodin solution, and then again washed with alcohol before opening the abdomen. The preparations for abdominal incision, indeed, for any operative procedure, demand the utmost cleanliness on the part of the surgeon and his assistants. Every avenue for the entrance of infection must be rigidly controlled. The operator and his assistants must diligently wash their hands and arms with soap and hot water, using the nail-brush for a period of ten minutes, even though they expect to wear rubber gloves. Gloves are worn to protect the patient, not the wearer, from infection. They must not be an excuse for neg- lect of surgical cleanliness, otherwise it were better not to use them. A glove may be easily torn or punctured during the operation, then neglect in cleanliness may mean grave danger to the patient. The purpose of wearing the gloves is defeated when the surgeon uses the fingers of the bare hand to press in place the fingers of the first glove he puts on. 14 : CARE OF GYNECOLOGIC PATIENTS The surgeon and all his assistants who have anything to do Fig. 1.—General ensemble Patient prepared for abdominal operation. with handling instruments, ligatures, sutures, or dressings must be gowned, masked, and gloved. Such preparations THE INCISION 15 should be preliminary to any manipulation of the material to be used in the operation. The instruments, suture and ligature material, the dressings, gowns, and all the parapher- nalia, for the operation should be carefully protected from exposure until needed. Consideration must be given to every step of the pro- cedure, and the effect of any misstep appreciated. The better prepared the operator, the more accurately he has planned the procedure, the greater the efficiency of his staff, the better will be his ultimate results (Fig. 1). THE INCISION The treatment of the great majority of visceral condi- tions within the abdomen demands an incision. The situa- tion of the incision will depend upon the particular structure involved. An incision for drainage may be made directly over the position of an abscess, whether it arises from a sup- purating appendix, gall-bladder, or from a local infection, as in cellulitis. The most frequent incisions will be limited to the median line, above or below the umbilicus. In pelvic surgery, either the median or the transverse, known as the Pfannenstiel, will afford ready access to the affected viscera. If the appendix is the sole cause of the procedure, and espe- cially if it has been the seat of recent inflammation, a right- sided incision over the semilunaris muscle, or by splitting the abdominal muscles, is generally preferred, although the appendix is readily reached through a median opening. Instruments.—See Fig. 2. 16 CARE OF GYNECOLOGIC PATIENTS Chromic and plain catgut, assorted sizes, sterile sheets, towels, and gowns. jemostatic forceps; 5, retractors; 6, retractor, self-retaining; 7, needle-holder; 8, needles; 2.—Instruments for abdominal incision: 1, Scalpel; 2, tissue forceps; 3, scissors, straight and The above-named instruments are for the mere incision. A more extended list will be named in the individual operations. THE INCISION 17 The median incision is one in the median line below the umbilicus. The operator stands to the patient’s left, with his assistant to her right. The cleft of the vulva and the umbilicus are landmarks for the incision. With the thumb and index-finger of the left hand he makes the tissues tense, Fig. 3.—Median incision. Combination retractor in place. Intestines walled back with gauze. while, with the scalpel in the right, the incision is carried through the skin and superficial fascia in the first upward sweep of the knife; the second sweep divides the aponeurosis, and if over the rectus muscle the latter is separated from its fellow, and by holding up the tissues with the left hand the 18 CARE OF GYNECOLOGIC PATIENTS deep fascia and the peritoneum can be opened without dan- ger to the subjacent coils of intestine. As soon as the peri- toneum is opened the intern and surgeon each insert a finger, incise the peritoneum the length of the wound, and, if de- sirable, extend the latter. The nurse hands a long folded gauze pack, by which the surgeon walls back the intestines, exposing the pelvic viscera. The median incision is em- F a Fig. 4.—Wound in process of suture. Peritoneum closed. Aponeurosis being sutured. ployed for the investigation of the abdominal contents when the condition is so obscure that pathologic lesions cannot otherwise be determined (Fig. 3). Such operations should be rare. It is also employed in the treatment of inflamma- tory conditions of the pelvis, for the removal of fibroid growths, for the extirpation of the uterus for cancer, and the excision of ovarian growths. THE INCISION 19 Pfannenstiel Incision.—This incision can be employed for the removal of small fibroids, cancer of the body of the uterus, to shorten the ligaments, separate adhesions, re- move the appendix, and for other local conditions when suppuration and active infection are not present. The large amount of connective tissue opened, which can be protected Fig. s.—Wound closed. with difficulty, makes its employment undesirable in suppura- tion and acute infections (Fig. 6). The operator, with scalpel in left hand, the abdomen made tense by pressing its surface upward, with the right makes a slight curved incision convex upward across the lower part of the abdomen, cutting through the skin, superficial fascia, and aponeurosis to the muscle. As the aponeurosis is 20 CARE OF GYNECOLOGIC PATIENTS opened, two fingers of the right hand are inserted, drawing toward the umbilicus, while the incision through the fascia is completed. Usually the apices of the pyramidalis muscles are firmly attached to the under side of the fascia and should be cut, which permits the necessary exposure of the recti muscles. Two fingers are pressed against them and the tissues lifted up, when the peritoneum can be opened verti- Fig. 6.—Pfannenstiel incision. cally. The intern and surgeon each inserting a finger, the peritoneum is cut the length of the wound. The structures thus lifted up, the peritoneum can be opened without danger to the intestines without the need of forceps. The intestines are packed back with gauze. The packing should be with a piece of folded gauze of good length, so that there will be no possibility of it being overlooked when the operation is com- CLOSURE OF THE WOUND ar pleted. The nurse in charge of the gauze should know just how many pieces have been issued, and see that they have r oe Fig. 7.—Wound closed. been counted before the wound is closed (Fig. 7). No gauze should be placed in or left in the abdomen except by the operator himself. CLOSURE OF THE WOUND In order to avoid repetition, the closure of the. wound and the detail of after-treatment will be considered at once for all procedures. The intra-abdominal manipulation hav- ing been completed, and gauze pads and instruments all ac- counted for, the final step in the procedure, the closing of the wound, is in order. The skin surface should be wiped dry and clean towels placed about the wound, especially 22 CARE OF GYNECOLOGIC PATIENTS where there has been soiling of the surface with discharges from the cavity during the course of the operation. The edges of the peritoneum may be seized with hemostats and thus made more readily accessible. The nurse hands the surgeon a long curved needle threaded with a No. 1 chromic catgut suture, with which he begins at the upper angle of the wound and picks up the peritoneum of each side, passes a suture, ties with three turns of the gut, and cuts one end of the suture short; then proceeds to use the suture, con- tinuously closing the peritoneum, so opposing its inner sur- face that no raw edge is inverted to come in contact with in- testine or omentum and thus afford opportunity for the oc- currence of adhesions. Three ties are made with catgut at its completion at the lower end of the wound. This pre- caution is necessary to ensure against the knot slipping and becoming untied, which would prove disastrous in a wound closed with continuous suture. The wound is wiped dry and all bleeding vessels secured. The nurse now hands a round- pointed needle threaded with No. 1 chromic catgut, with which one or more sutures are taken in the recti muscles to ensure their being held in contact. A cutting-edged needle here might injure a vessel, which would cause an accumula- tion of blood beneath the muscle, or the subsequent united aponeurosis affording a collection which if infected endangers the future healing and resistance of the wound. With the same sized chromic catgut, but with a long curved cutting- edged needle, the surgeon picks up the aponeurosis or deep fascia