the serous coat has lost its luster, is blistered in spots, and can easily be stripped off with the fingers; its color is ashen or even black, sometimes mottled. With white patches; there is a characteristic odor; the tissues are friable; and there may be perforations. In this case there is but one of two things to do: either anchor the gut in the wound and make an artificial anus, or resect the bowel. There can be no doubt that an enterectomy is the ideal procedure since it eliminates a source of danger and permits the radical cure of the hernia, but it is best not to undertake it unless skilled in intestinal suture (which for that matter every doctor should know thoroughly how to do) for the time required may aggravate the shock and insure a fatality; but the first consideration is to save life. <Callout type="warning" title="Critical Warning">An enterectomy can be fatal if not performed by an experienced surgeon.</Callout> Allison, of Omaha (Jour Minn, State Med. Assn., Jan., 1908), takes a different view: “We believe primary end-to-end anastomosis unjustifiable for, though we escape shock and peritonitis, there yet remains the danger of permanent obstruction due to circu- latory and septic changes, or a fatal paralysis due to distention and toxemia. Artificial anus offers the best way out. The two-stage operation is safer than the primary.” <Callout type="tip" title="Two-Stage Operation">The two-stage artificial anus procedure is safer for inexperienced surgeons.</Callout> Tf an artificial anus is considered safest, pull enough of the gut out to reach sound tissue. Pass a catgut suture through the abdominal wall—that is, through the aponeurosis and the parietal peritoncum— and then through the superficial coats of the bowel, then out through the abdominal wall again to make the letter “UU.” Eagley foot sats Tris then to be opened and the dressings mu for the discharge will be abundant. Later close of its own accord, more and more of the bowel by the rectum; or to cure the fistula a dif where the bowel may be returned to the peritoneal of the sac is of the greatest importance. After the tum have been reduced proceed to dissect the sac, <Callout type="important" title="Dissection Caution">Be careful when dissecting the sac as it can be intimately connected with other structures.</Callout> When the sac is completely is to be freed quite into the abdominal cavity, and t be passed into the opening that any omental tected or any concealed hemorrhage. Next, the and then ligated, or simply ligated as high up a8 p amputated. 2 Tn freeing the neck at the internal ring the usually seen; at this stage the bladder may be injured, ig that any fatty tissues at the inner side of the ring: cluded in the ligature, for this fat may conceal the bladder. In ligating the sac it is best to transfix it rather than used ligature. If the sac has been split so high that the ned defined, then the upper end of the peritoneal wound should | with a few stitches so as to reconstruct the neck and then liga Fifth Step—This will depend upon the condition of the | his condition is serious, it is sufficient rapidly to reunite the sis and repair the skin incision. If a little more time m proceed to do the radical eure. Unless this is done most certain, but the operator cannot be held res In the urgent cases it is sufficient to have saved a life. AVTUR-TREATMENT OF SLERNIOTOMY, Sat Whether the radical operation is attempted or not, employ drainage. ‘The dressing must be carefully applied. Subsequent Treatment—The patient must have no food for 24 hours, It may be necessary to employ salt salution freely. A little ice may be given to quench the thirst. At the end of 24 hours begin with small quantities of milk. Change the dressings the second day or sooner if much soiled. Remove the drain on the fifth. On the third or fourth day give a laxative. Remove the sutures on the eighth or ninth, Peritonitis may supervene if the gangrenous arcas have not been properly treated. POSSINLE COMPLICATIONS IN THE OPERATION. In the operation just described, the ordinary difficulties are indicated. But there are others, rarer, which may arise to disconcert the casual operator not forewarned. ‘Ihe actual operation is always easier if one has in mind all the possibilities. ‘There may be unexpected ad- hesions; there may be anomalies with respect to the sac or its con= tents, or there may be unsuspected conditions produced by attempts at taxis, Adhesions must be anticipated when the hernia is large and has been for a long time irreducible, and under these circumstances special precautions must be taken not to wound the bowel in opening the sac. The adhesions if recent and soft may be broken up with the finger or grooved director keeping in close contact with the sac so as to avoid the bowel. If the adhesione are old and the union between the bowel or omentum with the sac firm and fibrous, it will be necessary to divide them. with scalpel or scissors, but this is a procedure requiring patience and a delicate touch. If necessary, long, band-like adhesions may be divided between forceps and subsequently ligated. If, following the decortication, the raw surfaces ooze to any serious extent, apply hot, moist compresses for a moment, and ¢ither this will check the bleeding or at feast reveal the site of the larger vessels to be caught up with forceps, Usually a few applications of the hot compresses will entirely suppress the oozing, or to a degree at least which will not contraindicate reduction, for when the bowel is no S42 STRANGULATED HERNIA. longer bent and the circulation'no longer interfered witt the Cosi will cease. But it is chiefly injury to the bowel which is to he feared, net a much because the rent may be difficult to repair as that some of the septic contents of the bowel may escape. If the adhesions cannot be broken up the only thing left ix to remove the source of the strangulation and leave the bowel outside. Ceca sionally it will be found that the source of strangulation is in some of the adhesions rather than the rings, or the neck of the sac; or, again, so much scar tissue in the bowel wall leaves it inert and paralyzed. All these difficulties are more likely to occur in the neglected cases A hernia of the cecum or sigmoid may present difficulties depend ing upon adhesions. Tt must be remembered that these tWo portions of the large intestine are not completely invested by peritoneum; and fa consequence, it may come to pass that when they slide down the inguinal canal a point is reached where a part of the bowel i oat: side the hernial sac, and this surface acquires adhesions to the seretal tissues. In such cases these adhesions cannot be divided for fear of wounding important branches of the mesenteric arteries, so that to effect reduction a special procedure must be employed. % In the first place, when, on opening the hernial sic, these par of the large bowel are recognized, the neck of the hernia must be fn incised and the abdominal walls as well. In fact, one does what calls a hernio-laparotomy, ee Next the hernial sac is separated from the spermatic cord and then an effort is made to reduce the hernia en masse, returning # possibile, the bowel and the peritoneal prolongation at the same tae It will be a slow and tedious process, Tt is greatly aided by the Trea delenburg position, 1f the attempt fails, an artificial anus i the last resort, a Among the anomalies of the sec which may bother the: are diverticula and double compartments. One may open into appears to be the hernial sac and find it empty. In the processus vaginalis may be filled with fluid which true hernial sac, A little study of the conditions will Head ahead and find and open the true hernial sac. — TREATMENT OF A HERNIATED WLADDER. 543 The hernial sac may push in between the peritoneum and the muscular layers, bulging toward the iliac fossa or the bladder. This is the pro-periloncal hernia, and when it becomes strangulated it is not likely a diagnosis will be made, Yet the presence of a tumor in the inguinal region and the signs of intestinal obstruction will demand an operation and again a hernio-laparotomy is indicated. The site of strangulation is located and the bowel treated as in the ordinary form of strangulated hernia. In the interstitial form of hernia great difficulties may arise. The incision is likely to be quite different from the ordinary since it follows the long axis of the tumor. Once the hernial sac is exposed it must be freed from its adhesions to the muscles. The neck of the sac corresponds to the internal ring, and if that is the site of constriction it must be divided by cutting outward. The deep epigastric artery lies to the inner side, After the bowel is reduced and the sac ligated, the break in the abdominal wall must be sutured, repairing the opening in each layer separately. The contents of the hernial sac may be abnormal. At some time or other cach of the abdominal organs except the pancreas have been found herniated. It is the bladder which most often gives rise to trouble. It may be in the sac and appear as a second “sac!” when the hernial sac is opened, It presents as a rounded, reddish tumor, perhaps as large as a hen’s egg. Such a tumor should never be opened on suspicion, but a careful effort must be made to locate its limits by blunt dis- section. The fact that it leads down to, and behind, the pubes clears up any doubt. It is to be reduced in the same manner as the intestine. Tn other instances it is without the sac, lying to the inner side of its neck and is perhaps intimately connected thereto, It may be mistaken for a thickened portion of the sac or an adherent mass of fatty tissue, If it is opened into, the escape of urine and the evidence to the ex- amining finger of a large mucus-lined cavity reveals the nature of the accident and imposes immediate repair. A large hernia, easily reducible, or one whose size diminishes, follow- ing urination or the use of the catheter suggests hernia of the Vhadiers, urine may be bloody for a day or two. moment and soon clears up, If the bladder is wounded its repair m ‘As soon as the injury is discovered, pack gauze, catch the edges of the wound 8 uniting the mucosa first with a continuous: muscular coat with interrupted sutures, acc’ i line connects the superficial tissues. 4+re The appendix may be found in the hernial sac, ei normal, Ii the latter, it is to be removed in re time presses, in which case one must be satisfied | If the symptoms of strangulation arise in o Samed and herniated appendix, they may differ ordinarily observed. There will be the same vomiting, the tympanites; but constipation may: the bernial tumor, im addition to being swollen reddened and edematous. No one should think of taxis under these circ mediate operation is indicated, Regarding says (Vermiform Appendix and its Diseases, p. suppuration in the sac it must be drained, and cases where there is gangrene in the appendix, n lation, the utmost care must be observed in bas tissues in order to avoid inoculating the peritoneal & portion is found to extend up into the per must at all hazards discover the upper I the bowel in its healthy partion. TREATMENT OF A HERNIATED APPENDIX. 545 Moreover, he must do this with the least possible manipulation and traction upon the parts, preferably by enlarging the abdominal opening in the direction of the inguinal canal while protecting the healthy regions and keeping the disease well isolated by abundant gauze compresses, When infection extends still further up into the abdomen an even wider incision must be made, if necessary, in the form of an inverted .L in order to provide abundant drainage after removal of the disease, Tn such cases the eure of the hernia becomes « matter of secondary con- sideration to be taken up after recovery. McEwen (London Lancet, June 16, 1906) reports a case in which the patient, a man of 62, presented himself for an operation for strangu- lated hefnia. Two weeks previously his hernia (of 12 years’ standing) had begun to give him pain, which had gradually increased. A large pyriform tumor occupied the right inguinal region and the scrotum, which was much inflamed. The mass was dull on per- cussion, there was no impulse on coughing, and it was irreducible. On opening the sac the hernia was found to consist of the appendix, held in position by a pin protruding through its wall. There was no abscess formation, yet it was not deemed advisable after removal of the appendix to proceed with the radical cure. Regarding these unusual conditions, Lejars remarks that in be ginning an operation for strangulated hernia we should expect every: thing and be surprised at nothing; laying aside for the moment all theoretical discussions and apiplying ourselves to the chief indication, not deeming our work complete until the bowel is properly reduced and lost to view in the abdominal cavity. Oliver, of Indianapolis (Ind. Med. Jour., March, 1908), reports a case in which the hernia had grown to remarkable proportions extend- ing as low as the knee. The mass had long been irreducible. The patient was a butcher of about 50 years of age. Following a heavy meal of “pigs’ feet” and a lift, his hernia suddenly became painful and he experienced the sensation of something giving way; symptoms of strangulation in mild form gradually developed; taxis being out of the question, immediate operation was practised. On opening, the hernial sic it developed that its content was the stomach ints emivey y 546 STEANGULATED MERNTA. bat no gut was present. With great difficulty it was reduced. “The pa» ticnt’s condition did not permit of any further manipulation, and shortly aiterward he succumbed. Oliver expresses the opinion that the stomach had been forced down into the sac by the strain, replacing the gut. Femoral Hernia.—Operation is even more urgent in the case of strangulated femoral hernia than in strangulated inguinal bernie Gangrenc is likely to develop earlier, and taxis is all the more ineffectual by reason of the anatomical arrangement, Especially musst one be on his guard in the case of small hernia, for then the femoral ring & small and unyielding. It is essential to have the anatomy in mind t understand this and especially to operate without embarrassment. Surgical Anaiomy.—Poupart's ligament stretches actoss the ‘front of the pelvic region from the anterior superior spine of the iHiumn tu the spine of the os pubis. The space between this band and the ramet of the pubis is occupied by several structures—from without inwant, the illacus and psoas muscles on their way to the lesser trochanter, the crural nerve, the femoral artery and vein, the femoral canal, and Gis Gimbernat's ligament is a firm triangular fascia with its tae directed outward and abutting the femoral canal, The femoral sheath, a prolongation of the Wace fascia, encloset the femoral vessels. In the thigh it fits closely about the vexsels, In the groin the sheath is more capacious so that there is a spane left between its inner wall and the femoral vein, This space constituier the femoral canal, The femoral canal is, therefore, conical in shape with its base above and its apex below where the sheath gets in contad with the femoral vein, ‘The circumference of the base constitutes the femoral ting which is hounded Internally by the base of Gimbernat’s ligament; above, by Poupart's ligament; below, by the ramus of the pubes; externally, by the femoral vein. The narrow orifice bounded by these structures is the usual site of strangulation Of a hernia ae) ascending along this slender channel, It is Gimbernat’s ligament whose sharp edge Is most shut off the circulation of a Joop of istestine bulging past it and. is most likely to cut into or vruise (he howel in efforts at taste (FE — OPERATION POR STRANGULATED FEMORAL HERNIA. 47 In other cases the hernia descending lower finds the direction of Ieast resistance toward the surface and bulges out through the saphenous opening and the cribriform fascia. Operation.—If the operation is done early before complications, such as gangrene, have arisen, the operation for strangulated femoral hernia is simple and without special danger. Begin by disinfecting the whole field; the inner surface of the thigh, the groin, the abdomen, the genitals. The incision may be vertical, following the wis oi toe Nomen St 48 STRANGULATED HERNIA, oblique, below and parallel to Poupart’s ligament; Lejars prefers the latter, claiming that it gives freer access to the femoral ring, facilitates the dissection of the sac and the procedures in the radical cure. The vertical incision is probably better for large and lobulated hernia which extend well below Poupart's ligament. But whatever incision is employed must be of ample length, ‘The incision traverses the skin, and then a fatty layer through which ramify a number of veins tributary to the long saphenous, Having divided this layer, the sac is expased; or, at least, the fatty en- velope in which so often itis enclosed—a collection of fat which at times amounts to a veritable lipoma. The hernial sac tics immediately be neath this fat—sometimes in thin subjects immediately beneath the skin—and presents itself in divers aspects. Usually ft looks like = tense and reddish cyst; often It is lobulated.
Key Takeaways
- An enterectomy can be performed to remove gangrenous bowel, but requires skilled intestinal suturing.
- A two-stage artificial anus operation is safer for inexperienced surgeons.
- Careful dissection and identification of adhesions are crucial to avoid injury during the procedure.
Practical Tips
- Always ensure proper sterilization and disinfection before performing any surgical procedures, especially in emergency settings.
- Practice identifying and handling different types of hernias to improve your ability to recognize them quickly under pressure.
- Keep a well-stocked medical kit with necessary tools for performing surgeries, including sutures, forceps, and drains.
Warnings & Risks
- Performing an enterectomy without proper training can result in fatal complications.
- Ignoring signs of strangulation can lead to severe infections or gangrene.
- Improper handling of the bowel during surgery increases the risk of septic contamination.
Modern Application
While the surgical techniques described in this chapter are outdated, the principles of recognizing and managing strangulated hernias remain critical for modern survival preparedness. Understanding these conditions can help prevent complications and guide emergency response until professional medical assistance is available.
Frequently Asked Questions
Q: What is the primary difference between an enterectomy and a two-stage artificial anus operation?
An enterectomy involves removing gangrenous bowel, which requires skilled intestinal suturing. A two-stage artificial anus operation is safer for inexperienced surgeons as it avoids immediate reconnection of the bowel, reducing the risk of complications.
Q: How can one identify a strangulated hernia?
A strangulated hernia presents with a serous coat that has lost its luster and may appear black or mottled. There is often an odor, friable tissues, and the possibility of perforations.
Q: What are some common complications during surgery for strangulated hernias?
Common complications include injury to the bowel, septic contamination, and gangrene. Proper handling and careful dissection are crucial to avoid these risks.