CHAPTER VI.
GENERAL TECHNIC OF LAPAROTOMY.
Since so many urgent conditions require a laparotomy, every doctor should be familiar with the general technic of the procedure without regard to any particular purpose for which the abdomen may be opened. .
For the purpose of ready review, the various difficulties and thelr management and the after-treatment are briefly outlined.
Preparation of the Patient—Whenever possible, the patient should be under a preliminary treatment for two or three days in order that the bowels may be thoroughly cleansed, the field of operation sterilized with certainty, and the functions of the organs noted, In emergency york, these details cannot, of course, be so definitely regulated, but to omit any of them is a handicap.
To have the bowels emptied by castor ail and enemata is the best prophylaxis against metcorism, which may be a source of embarrass- ment to the operator in the course of the operation, and a source of discomfort and perhaps danger to the patient subsequently.
However urgent the operation may be, the sterilization of the field must be definite, even though the methods be abbreviated. To scrub with soap and water, shave, wash with alcohol or ether to remove the oils, and finally bathe with bichloride solution and cover with bichloride compresses until ready to make the incision is to realize @ practical asepsis so far as the skin is concerned; or the sterilization may be even more rapidly accomplished by washing, shaving, and dry- ing the skin, and then painting with tincture of iodine
To have a definite knowledge of the patient's temperament, of the action of his circulation and respiratory organs and of his kidueys is to forestall many difficulties and dangers. At \east a WAX exoroada
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464, GRNERAL TECHNIC OF LAPAROTOMY,
should be washed out, and the bladder emptied before tl
Incision.—The operator may stand on either side. It is p to stand to the patient’s right and cut from above toward the p ‘supposing a median laparotomy.
The skin and subcutaneous fatty tissues are divided first. the small vessels and gently sponge. In the case of abscess chronic inflammation, the bleeding is tikely to be rather free but
dangerous.
‘The aponewrosis, when possible, should be divided in the linea because the bleeding will be leas and the access to the perite m readier. On cither side of tie middle line the incision opens into th ‘sheath of the rectus, whose inner border should be displaced to outer side or its fibers split. ‘The edges of this fascia should be c with forceps in order to be more readily recognized im the cours repair.
The peritoneum is now exposed, covered usually by fatty tissue, more or less thick. Catch up a fold of it between two fo and make a small opening with either knife or scissors, using ¢
not to cut into the bowel or omentum. 4
The lips of the peritoneal wound are controlled with forceps * are to be left attached; and now enlarge the opening in either d ‘using the finger as a guide and asa protection to the bowel. App ing the pubes, guard against wounding the bladder, af which tt no danger if it has been previously emptied. In any event, it c readily located by the sense of touch. Protect the Cut Surfaces.—When the peritoncum Is opened necessary extent, apply two wide compresses of gauze, So a5 to pletely cover the incisions and attached forceps, tucking the ed each compress under either side of the peritoneum, to diminish the chances of infection and to prevent brui peritoneum.
In like manner, and for the same purpose, the fara oe dealt with are packed off from adjacent structures with presses which are not only more efficient than amall ones, Jess likely to be lost within the peritoneal cavity. The
‘HEMORREAGE IN LAPAROTOMY. 405
ible assistant must always know how many compresses are brought into use, and they must be accounted for befare the cavity is closed.
Management of Peritoneal Adhesions.—The novice and even the most practised surgeon may experience the greatest difficulty in sepa~ rating adherent organs, their peritoneal surfaces glued together as the result of inflammation.
In the case of recent adhesions, they are soft and easily broken. In other cases, they consist of bands which need only be divided with scissors; but finally they may bind together large areas of adjacent structures so as often to render them indistinguishable.
Even bere with a little patience one may often find a planeof cleavage, ‘especially if the parictal peritoneum is involved. If the organ cannot be separated from the parictal peritoncum, a segment of this latter is to be cut out and left attached to the viscus concerned. In the case ‘of the omentum it is to be ligated twice and cut between, In the case of the intestine, the greatest care must be used not to break through its
In general, intestinal adhesions discovered in the course of operation ‘are not to be broken up except as they interfere with the work in hand orarelikely to obstruct the bowel,
Tf no plane of cleavage can be found, then the other organ involved must be deprived of its peritoneal coat to protect the gut. If the sur face of the intestinal loop is left raw after the separation, the Lembert ‘suture should be employed. If the bowel wall is torn through, it must be repaired by two rows of suture: a through-and-through and a Lem- bert suture.
Hemorrliage.—The visceral blood supply is complex; to have its anatomy clearly in mind is a great advantage in hemorrhage from larger vessels, To locate the vessel at fault, to damp it and ligate quickly, speeds the operation. Capillary oozing can generally be con- trolled by a few moments! application of hot compresses, A compress wet with alcohol will often promptly check free bleeding. If the oozing is persistent at the end of the operation and measures applied have failed to check it, the abdomen must not be closed withour drainage.
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466 GENERAL TROUNIC OF LAPAROTOMY,
‘To insure against recurrence of hemorrhage as well as to prevest infection and adhesions, all raw surfaces should be covered over with a peritoneal coat. It is never desirable and seldom to leave a denuded area in the peritoneal cavity, Use of the ! suture and of the free omentum enables one w obliterate them. Suck ‘as must be left should be sprinkled with aristol_ of
Drainage-—The old dictum, “When in doubt, drain,” does not with such force to laparotomy as formerly, In fact, there are bold enough to say, “When in doubt do not drain.” Stil it must be admitted that, in spite of drawbacks, drainage is a real safeguant against infection, One should drain, then, when any septic proces: is present or is likely to develop, as in the case of perforating wounds cof the intestine. y
Drainage must be employed whenever it is impossible to contr bleeding from raw surfaces. If there is no infective process present in the peritoneal cavity, if there is no obvious reason for any to develop later, the abdomen fs to be closed completely. ¥
The preferable method of draining the abdominal cavity te & rubber tubes. This is the only method available if pus i present. If the main object is to get rid of blood, then the thbe should contain a wick of gauze which should rest upon the oozing surface that it may serve the double purpose of hemostasis and! drainage. ;
As soon as the oozing has ceased the gauze wick is to be withdraws: while the tube remains. ‘The tubal drains are to be removed as Sonu as the danger of sepsis is passed ’
Repair of the Abdominal Wall—Suppose the operation complete The final inspection of ligatures and sutures is made, the cavity it wiped out, the compresses are removed and counted, the vessels i” the abdominal wall that were clamped are ligated, if necessary, amd repair of the abdominal wall is begun. ”
‘The peritoneum, to which the forceps still remain attached, is pulled up into view, If the Trendelenburg position has been used, the table’ is now brought to the horizontal; the intestines are brought back date place, the omentum spread out over them, and a compress applied ti
the bowel while the peritoncum is repaired with a combs |
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APTER-TREATMENT OF LAVAROTOMY, 467
No, © catgut suture. The compress is withdrawn before the last two or three stitches are passed.
The apeneurosis und muscles are now repaired with continuous ciromic. gut suture,
The skin, finally, is to be repaired with inerrupled silkworm-gut stdures, passing some of them deep enough to include the muscles and aponcurosis so as to obliterate any dead spaces, If coaptation is not perfect, a few superficial catgut sutures may be used as necessary, One may close the skin simply by the continuous catgut or chromic gut suture or, as many prefer, by the subcuticular stitch.
Of course, if drainage has been employed, the closure cannot be complete, though the suturing is to be carried close up to the tube. In case great haste is required, the abdomen may be closed by a few through-and-through sutures of silkworm-gut.
After-treatment —In the uncomplicated case, the after-treatment is simple. The patient is put to bed where he can get plenty of fresh air and hot-water bottles put to his feet. As he recovers from the anes- thetic, he is given water cautiously for the first twenty-four hours. After that, liquid nourishment should be given in small quantities at frequent intervals. The bowels should be moved on the second day by a light soapsuds enema.
Tt is rare, however, that these patients do not have some complica~ tion, If there was much shock or much hemorrhage, or if the anes- thesia was prolonged, give normal solution by one of the three methods, hot coffee by the rectum and whatever cardiac stimulant may seem in- dicated, stryehnia, brandy, or camphorated oil.
If the pain is severe, small doses of morphia hypodermically should be given until the patient is comfortable.
If there is much nausea, try a glass of warm soda-water which will probably be thrown up, and thus washes out the stoach, If the nausea is quite severe, wash out the stomach and put the patient in a half-sitting position, If the thirst is extreme along with vomiting, enemas of normal salt solution give the most relief.
Sometimes 5-15 minims of aromatic spirits of ammonia, given hypodermically, tend to relieve the nausea, while acting as a diffusible stimulant.
468 GENERAL TECHNIC OF LAPAROTOMY.
If there is much flatulence or meteorism, give minute doses of calo and empty the bowel with soapsuds enema, If this does not | relief, the enema consisting of two ounces af Epsom salts and glyc) and one ounce of turpentine may be employed,
A special line of treatment is required if postoperative ileus devel
(see page $17)