Chapter Von Drainage).
Close the abdominal wall by three tiers of suture; the peritoneum with a continuous ric. 143—Avolyipx Lembert suture of catgut, the muscles with chromicized ‘oa catgut, and the skin with silkworm-gut. Apply a dry dressing.
Subsequent Care—Order complete rest and absence of food for forty- eight hours, not even excepting milk. ‘To quench the thirst, let the patient suck a cloth saturated with water. Inject salt solution if there are signs of collapse, It will nearly always be expedient to give salt solution cither by rectum or subcutancously; in the worst cases by intravenous infusion.
Change the dressing the following day. It will probably be satu- rated with bloody serum, On the second day remove the tampons and replace with smaller ones. On the fourth day remove the drain- age-tube, if employed, and replace with smaller onc, which may be dispensed with after the eighth day.
Prognosis —The prognosis will depend upon the extent of the injuries and the skill of the operator.
Death may occur from hemorrhage or peritonitis shortly after the operation, or about the eighth or tenth day if the suturing has been
imperfectly done,
478 LAPAROTOMY FOR TRAUMATISM.
Fecal abscess and fecal fistula may result, requiring a ater operation or which may eventually cure themselves,
Complete recovery happily very often occurs and would be the rult if the doctor had the judgment or authority to operate within thy first few hours after the traumatism.
WOUNDS OF THE STOMACH.
If the injury involved the upper pole of the abdomen, the stomach must be examined carefully. Extensive injuries are offen overlooked, An escape of gas and bleeding may point to the situation of the lesion,
Pick up the stomach with gauze to get a firmer hold, and examine the anterior surface systematically. Repair any wounds, as in the intestine by two rows of suture; the one including all the coats, the other only the serous and muscular.
In the case of gunshot wounds, examine the pesterior surface. To reach the posterior surface, Auvray insists upon a large incision in the gastro-colic omentum along the lower border of the stomach, form large incision facititates examination and does not compromise the of any structure: If even then one cannot gain full access, be adyines an exploratory gastrotomy (Revue de Chirurgie, Nov. to, 1906).
‘The posterior surface may be reached another way, by turning up the transverse colon and opening the transverse meso-colon. To prevent the spread of fluids which may escape from the stomach) the Geld must be carefully walled off with compresses as the explora: tion proceeds. If the wound can be felt but is impossible to be semm) then no attempt must be made to suture, but the cavity is to be thar oughly drained.
If there has been much loss of substance, it may be necessary todo, A gastro-enterostomy.
WOUNDS OF THE LIVER.
If the nature of the abdominal injury keaves no doubt that the liver is wounded, it may be advisable to vary the procedure described from the first. A support under the back tilts the abdomen so that, the intestine drops down toward the pelvic cavity, and at the same time, the liver is bulged forward and made more accessible
al
TREATMENT OF WOUNDS OF THE Livik. 479
‘The incision beginning at the ensiform cartilage may follow the costal arch, dividing, if necessary, the right rectus muscle, It may even be necessary, in order to reach the upper surface of the liver, to resect the tenth, ninth, or eighth ribs,
You may find on examination of the viscera that the liver has been contused, and there is evidently a hematoma formed beneath the cap- sule, Itis better not to disturb it unless the conditions seem to indicate continuation of oozing.
There may be an open wound of any character or extent with great hemorrhage. One should attempt to catch up and ligate the bleeding points, employing a fine clip or artery forceps. The veins, as well as the arteries, will stand the strain of a ligature, but may need to be dissected loose from the liver substance before the ligature can be applied.
Af the patient ie not too weak, attempt repair by suture. It is a Little difficult, but quite possible and certainly desirable.
Employ a blunt-pointed needle and do not push it through boldly, but slowly, and as you push, gently oscillate the needle. In this manner, the point may slip by the vessels, Employ a large catgut suture, as a fine suture cuts through the soft tissue (Fig. 348),
Van Buren Knott (lowa Med. Journal, Oct., 1907) recommends inserting a strand of catgut parallel with the liver wound, tying the ends of the strand over small skeins of catgut to prevent tearing. ‘Transverse interrupted sutures are then passed so as to include the parallel sutures first passed.
Failing to suture, there is nothing left but the tamponade, and this, of course, is the only thing available in lacerated wounds.
Wathen, of Louisville, even advises (Int. Jour. Surgery, July, 1906) that the average operator use the tampon from the first to save time and trouble. The gauze must be packed into the wound with firmness to prevent further hemorrhage, and its end brought to the external wound that it may be subsequently removed.
Haynes, of New York (Annals of Surgery, July, 1907), describes & Case illustrative of some of the difficulties of treatment and the sequel of liver wounds.
Patient, a man of twenty years, was brought to the Harlem Vomit
Fie se Suture of the liver, (Meywibun)
the costal arch, the posterior wound could be reached and felt by seen, readily admitting two fingers,
By the sense of touch, an jodoform wick was packed into this w Bestia. salir one introduced into the _anterior wound, and
SUTURE OF WOUNDS OF THE PANCREAS. 481
control the hemorrhage, and so the liver was forced up against the diaphragm and held by a large Mieulice tampon below the liver.
‘The rectus was sutured. The peritoneum was repaired with the falciform ligament ifcluded; the abdominal walls sutured above and below the gauze wicks.
‘On the tenth day the tamponade was removed; and a few days later were removed the gauze wicks, for which rubber tubes were | substituted, a discharge of bile and pus being present.
At the end of the third week it became necessary to secure addi- tional drainage, and the ninth rib was resected in the axillary line, where, in the meantime, the bullet had been located; the costal and phrenic pleura were sutured, and the pleural cavity thus shut off. ‘The diaphragm was opened, the pus drained out and a long tube passed from the anterior to the posterior abdominal wounds, and a smaller one left in the posterior wound.
The progress of repair was slow but sure, five months clapsing before the cure was complete.
It should be remarked that very rarely after gunshot wounds of the liver Is there notable external hemorrhage, One must determine the degree of injury from the signs of internal hemorrhage and the evidences of peritoneal reaction which later develop.
WOUNDS OF THE PANCREAS.
Do not forget to examine the pancreas in wounds of the upper
gone of the abdomen. Reach the pancreas from above the stomach, opening through the gastro-hepatic omentum. Carefully mop out the fluids, blood and pancreatic juice. Pack the site with compresses and try to sulure. Sometimes two three deep sutures will coapt the wound surface and completely the hemorrhage. If. the tail is much crushed, resect it and ire the stump. Use gauze and tubal drainage. If the patient not die, he may have a subphrenic abscess (Figs. 349, 350)-
. WOUNDS OF THE SPLEEN.
b# Any but the slightest wound of the spleen is universally awd cayhidsy
‘Natal from hemorrhage unless treated. One naturally thinks of saitsx- eA
are no adhesions, though, if there are, failure is almost Under such circumstances, as Moynihan suggests, the only
Noetzel (Beitrage z. klin, Chirurg.) reviews his 1 six cases in which he removed the spleen for injury and conclu that splenectomy is the only safe way of securing hemostasis. and tamponing may arrest bleeding for a time, but there is danger that it will return.
Fic, 349,
Fics. 349 and 330.—Meth fronmdeges arn then sutarat
Holliday, of Portsmouth, Virginia, reports a case illustrating the: subject (Virginia Medical Semi-monthly Journal, January 11, 1905)5 patient, boy, age 15, was struck in left side by a flying pulley, fracturing his arm in several places and contusing the abdominal wall, Hie condition shortly became serious; temperature subnormal, absolute dullness on the left side, and marked rigidity. Immediate operation: The patient was almost eviscerated before the bleeding could be located, but which was finally found to proceed from the lacerated external surface of the sp ; a splenectomy was quickly done, and the abdomen closed without drainage. Convalescence was @aay and uneventful.
Splenectomy.—The operation following rupture generally finds the incision made in the middle line on account of the indications for
hemorrhage.
EXTRAPERITONEAL WOUNDS OF THE KIDNEY, 483
The spleen is brought up into view and delivered from the abdom- inal cavity, avoiding any strain upon its pedicle, for the veins have extremely thin walls.
Liyate and divide the pedicle. Transfix the pedicle with a double ligature and tic each half separately, and finally tie the whole pedicle in a single ligature. ‘The pedicle is next divided, the spleen removed, and its bed examined for any bleeding points. The under surface of the diaphragm is very likely to present some oozing.
Fiske, of Brooklyn, describes a case which illustrates the variations in the procedure. (Annals of Surgery, Jan., 1908.)
A man of twenty-five years was brought to the Kings County Hospital with a bullet wound in the left side corresponding to the spleen. The symptoms pointed ¢o visceral injury and intra-abdominal hemorrhage. An incision was made over the outer border of the left feetus muscle from the costal arch to a paint midway between the umbilicus and symphysis. The stomach and intestine were found to be uninjured. A perforation in the transverse meso-colon was Te- paired, but the hemorrhage continued, A transverse incision was made and the spleen examined, revealing a rent which admitted two fingers. ‘The spleen was pulled up into the wound, the pedicle clamped and Ugated en masse. After removing the spleen, the vessels were ligated separately, the abdomen was flushed with saline solution, a small gauze drain left in contact with the stump, and the wound closed with through-and through silkworm-gut sutures. ‘The tem- perature subsequently did not rise above roo, The drain .was permanently removed on the fifth day. ‘The patient left the hospital at the end of the third week, entirely recovered.
WOUNDS OF THE KIDNEY.
If, while examining the viscera in the course of the laparotomy,, you find a ruptured renal pelvis or a seriously lacerated kidney bleed- ing into the peritoneal cavity, remove the kidney. Make a longitu- dinal incision in its peritoneal covering, strip the organ out of its bed and, lifting toward the surface, free the pedicle.
Ligate the ureter first and then, if possible, eda ol tne wemwdo
484 TAPAROTOMY FOR TRAUMATISM,
separately. If the oozing persists, leave a Miculicz drain or a rubber
tube.
Intra-peritoneal rupture without injury to other viscera is Very rare.
Exira-peritoneal wounds of the kidney do not, as a rule, require intervention.
That the kidney has been involved will be suggested by pain, frequent micturition, and bloody urine.
Rest in bed, morphia, and limited diet are the special indications. An abdominal binder may give relief.
Eliot (American Journal Surgery, Nov., 1906) has observed twelve — eases of subcutancous rupture of the kidney. In seven cases there | was not sufficient extravasation to make a perceptible tumor, and the diagnosis was made by the hematuria and the tenderness over the kidney and persistent rigidity for a number of days,
In the remaining cases a well-defined tumor appeared in the fli costal space, becoming more sharply outlined as the rigidity dis appeared. In five or six weeks, the tumor disappeared. In me instance was operation necessary.
In such cases of extra-peritoneal rupture as require operation, the lumbar route should be chosen, Operation is indicated from the fine if the violence was known to be great and a large tumor forms ise mediately, An operation is indicated at ony time symptoms of sepait appear.
Morris Miller reparts a case (Annals of Surgery, Feb., 1908) of « man who fell, striking his left side over the lower rib. He felt faint, and almost immediately passed a quart of blood by the urethra and later many clits. Miller saw him at the hospital an hour and a Ball later. There was no shock, but the side was rigid and tender, and am indistinct dull mass could be felt in the loin. An oblique tumbar incision revealed an extensive rupture of the kidney with much hemor thage. Wicks of gauze were placed in front and behind the kidney and the ruptured segments pressed together. The patient did well, the hemorrhage gradually ceased, though twice after the fifth day blood appeared in the urine. On the twelfth day the packing: removed, and the opening finally healed. Gibbon, commenting
the case, remarks that temorthage severe exough to require
—
REPAIR OF WOUNDS OF THE LADDER, 485
does not usually mean injury sufficient to require nephrectomy. ‘The question of nephrectomy must be decided when the kidney is exposed.
Stewart adds that the two early indications for operation are a progressively increasing hematoma and constitutional symptoms of hemorrhage. In several cases of moderate bleeding he had operated, and afterward been sorry he had interfered.
WOUNDS OF THE BLADDER.
Wounds of the bladder, if not previously suspected from the nature ‘of the abdominal injuries, are inferred irom the presence of urine in
Fro. 341.—Repair of ruptured bladder Applying through and throuyh euturee Subse-
il a he pariotal peritoneum wil peuvent sea ebecrae na esc aed yan mean es the peritoneal cavity. Sometimes the rent is hard to locate, Inject the bladder with normal salt solution and observe its mode of entrance into the peritoneal cavity.
et a ny a a The result may he tested by filling the bladder with norm tion, and any defect repaired (Fig. 351).
‘A catheter should be leit in the bladder for draiaage and the
Yea. 553-—Van Woal’s Wack’ ateceral an aretetai anattomonn matemnende (Hroew) ‘Giles
age kept up for two or three days. Subsequently, the bladder sh be emptied by aseptic catheterization for a few days longer, peritoneum should be drained for the first forty-eight hours, ‘This mode of treatment applies to the intraperitoneal the bladder. The extraperitaneal wounds should be treated same principle, but often, under such circumstances, the must be content with suprapubic drainage of the bladder’ wound has healed, 4
——
ANASTOMOSIS OF THE URETER. 487
WOUNDS OF THE URETER.
If it is discovered that the ureter is wounded either by the trauma or in the course of the operation, an effort should be made at repair. Several methods are available. If the injury docs not amount to complete division, a few perforating sutures followed by Lembert sutures may succeed. Small wounds usually heal readily, but it is safer to use drainage.
If the separation is complete, both ends of the torn ureter may be ligated, or the kidney may be removed, but naturally it is preferable, if possible, to establish an anastomosis, Under various circumstances, the proximal end may be anchored in the bladder or in the bowel, or the two ends may be brought together.
Van Hook’s termino-Jateral anastomosis is generally applied. The technic may be briefly described in this wise:
Ligate the distal portion one-quarter inch from the end and make a longitudinal slit double the diameter of the tube in length. Split the proximal end also for one-quarter inch, beginning at the free end.
Pass the sujures. Employ a long catgut suture threaded on a needle at each end. One-eighth inch from the end of the proximal portion of the ureter, pass the two needles from without inward (Fig. 352). Carry the two needles through the split in the distal portion, into the lumen and let them emerge one-half inch below the end of the split (Fig. 353). Tighten the suture, which will have the effect of invaginating the upper segment in the lower (Fig. 354)- Around the line of contact run a Lembert suture, and cover with omen tum or peritoneum.