CHAPTER XIV, ENTERECTOMY. INTESTINAL ANASTOMOSIS.
Resection of a segment of the small intestine may be a necessary part of several emergency operations. It may be required following gunshot or other lacerating wounds of the intestine; it may be neces- sary in certain wounds of the mesentery and in the gangrene of strangu~ lated hernia.
Large wounds of the gut, those which carry away more than one> half the circumference, require resection, for any form of repair is likely to result in stricture. In the case of multiple perforations, it is safer to resect than to attempt separate repair of the orifices. A small wound of the omentum near the intestinal border may require an extensive resection, for an inch of mesentery at that level may contain the blood supply of two feet of intestine.
Resection of the bowel implies anastomosis, and this may assume one of three forms: it may be end-to.cnd—termino-terminal, termino- lateral, or latero-lateral.
The end-to-end anastomosis is preferable following resection. The method employed may be either by suturing—circular enteror- thaphy—or by the Murphy button or some of the other mechanical devices, such as Robson's bone bobbin or Frank's decalcified bone coupler, With the great majority of surgeons, suturing is the method of choice, although the casual operator may not yet be ready to dis- card the mechanical device.
Moynihan, in his great work on abdominal operations, sums the matter up in this wise: “The use of mechanical appliances is no longer necessary; these have played their part—a most important part, I gratefully admit—in the development of surgical work, and it is now time that their surgical use should be abandoned. They have been useful, nay, indispensable steps in the march of progress. To Murphy above all other surgeons—for his instrument is one of the wo. Wor
373
Si4 EXTERECTOMY, INTESTINAL ANASTOMOSIS,
genious mechanical contrivances ever invented—we should gratefully acknowledge the debt we owe. The weightiest argument mechanical aids to anastomosis is this—they* are unnecessary. By their aid we do not accomplish anything which cannot be
with equal rapidity and greater safety by simple suture. We have nothing to gain from their use and we risk much by leaving something behind which may be and has been the direct cause of danger and of death. The day of mechanical aids is over, ‘The buttons and the bobbins, the clastic ligatures and the forceps of many forms have ao more than a historical interest.”
Technic of Resection.—The first essential of this procedure i that all the impaired gut be removed. Otherwise subsequent slough and perforation are almost a certainty. ‘There is a limit, of course, i» the length of the segment which may be safely removed, but im the ordinary operation one need not fear to remove too much. Cases ane ‘on record in which as much as ten fect of the small intestine have been removed with recovery, As Moynihan said, it is not so much a ques tion of how much is removed as how much is left to carry on the tm testinal functions. A second requisite in resection supply of the bowel be left unimpaired. Lack of pet respect may pullify an otherwise carefal operation.
The integrity of a given part of bowel itesdy Sa the condition of the vessels which arise from the last arterial arch to supply it. It must be remembered that the vasa intentini temuis break up into a number of freely anastomosing arches, but the terminal branches anastomose but little, It is this character of thecircule. tion which determines the mode of section of the
‘The third peincipte tly to be borne in mind bs that the pest toneum is to be completely protected from contamination by the bowet contents, It is true of all the hollow viscera that thelr contents are more or less septic, always sufficiently so to produce peritonitis, “The bowel, then, must always be temporarily constricted beyond the limiteof the section. This is ordinarily done by means of intestinal clampsoe hy elastic ligature or by gauze strips passed through: a batton-bole in the mesentery. a
Not only must the intestinal contents be restrained, But also the
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RESECTION OF THE GUT, $75
field of operation must be shut off from the peritoneal cavity and from contact with the rest of the viscera by means of sterile compresses. ‘The larger and more deeply placed of these are not to be removed until the end of the operation; the smaller and more superficial should be changed from time to time as soiled.
To resect a porlion of the intestine, then, begin by getting the
Pio, 422. —Reswetion of the bowel; showing linor of incision of bowel and omentum.
injured coil well into view and pack around it with sterile compresses. It may be advisable as a further security now to put the patient in the ‘Trendelenburg position. Strip the portion of bowel to be removed, #0 as to emply it, and apply a clamp well beyond each end of the con- demned segment. The clamps are not placed directly across the bowel, but obliquely, so that more of the convex than of the mesenteric border is included. A portion of the mesentery is included in the bite of the forceps.
576 ENTERECTOMY, INTESTINAL ANASTOMOSES.
‘The tines of the section are prolonged into the mesentery so that they mect just short of the nearest arterial arch, It is better to ouke the base of the mesenteric wedge even narrower than the mesen teric margin of the intestinal segment. ‘There is then scarcely amy danger that the circulation will be impaired (Figs. 422, 425).
Technic of Anastamosis.—(a) By suture. Employ two fines of
Kewction of bowel: showing snement of bowel afl cmsmmtsen freed
suture. One perforates the bowel wall, brings the cut edjges inte ace curate contact, and is hem
suture. The other p wr even better the #1 suture brings the serous surfaces into contact, burtes the 3 sutures and effectually prevents any of the bowel content from resebe I ing the peritoneal cavity. Most surgeons employ a straight neoihe and silk, Moynihan likes the curved needle and cellaloid thread,
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END-TO-END ANASTOMOSIS. 5i7
Ta introduce the suture begin by placing the clamps side by side, bringing the posterior surfaces of the bowel into contact. Con- nect these two surfaces by a continuous sero-serous suture, extending from the mesenteric border to the convex border (Fig. 424). Leave the thread long where tied at the point of beginning and catch it with forceps. On reaching point ‘“B” leave the needle, still threaded, but wrap it in gauze and lay it aside for the moment.
Now begin the perforating-suture at the mesenteric margin. The two leaves of the mesentery separate bere to encircle the bowels,
Pie, 424.—End-to-end anastomonin: the first part of the pero-scroux or Lembert ‘eature applied. Beginniva the iciuslve sature. “(Binne)
leaving a part of the surface bare. The stitch must be passed so as to
bring the mesentery in contact with this bare area.
Proceed in this manner: Pass the needle through the bowel wall (beginning with the right side) about 1/6 inch from the cut edge, enter ing the mucus, emerging from the serous coat just where the mesentery reaches-the bowel. Carry the needle over and across to the left side, pass it through into the lumen, reversing the first puncture. Pass it next from within out, perforating the wall near the mesenteric juncture, and finally perforate the right bowel wall again, passing from without fnward. The knot is tied within the lumen of the gut at the original point of entrance. The edges of the mesentery being thus brooms
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578 ENTERECKOMY. INTESTINAL ANASTOMOSIS.
together, the suture is carried continuously around the whole cireum- ference of the gut (Fig. 425). The punctures are x/10 to 1/52 feck apart and the work is facilitated by keeping the thread taut, which at once tightens it sufficiently and brings into view the site ol the mext pene ture. The end of the suture is knotted, the thread left long af the beginning and thes the perforating suture is completed. Remove the clamps.
3 Een
‘ihe cite alle est te bears A tae It remains to complete the sero-serous suture which was temporarily abandoned. It is carried from the conver border on around #2 the mesenteric border, and when that point is reached the perforatiog wature is completely buried. Knot with the thread left long in the be ginning and beld with forceps, and thus the Sero-serous suture be cam pleted (Fig. 426). Finally suture the rent in the mesentery, ‘Thi must never be neglected, else it may be the site of a strangulatel The line of suture is to be carefully wiped, the compresses re and the loop returned to the alxtominal cavity.
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ANASTOMOSIS BY MURIMY DUTTON, 579
(b) By the Murphy button (Pig. 427). The bowel is resected as de- scribed above. Begin by passing a purse-atring suture around the bowel near its cut edge, involving all the layers. ‘The chief concern is to get control of the mesentery where its layers separate. To do this
Gee
Pro. 426,—End-toend anasto- Pro, 427-—Murpy butter evoalt comple fal hand ta be PS IY i Rooted. ite
Fic. 43k Purse Pin, 420 —Anantymonis with Mushy button cormpletnd sera salure run Citnase after Dacor.) sot lo coin ed
reeens eewentery (6) a
Co" Rereart
pass the needle through one layer, on into the lumen of the bowel; out again through the bowel wall and through the other layer of mesen: tery (Fig. 428).
When the suture is puckered the intermesenteric space is obliterated.
580 ENTRRECTOMY. INTESTINAL ANASTOMOSIS.
Now grasp onc half of the button with forceps and introduce it inte the end of the gut so that when the purse-string suture is tightened it will fall into the groove in the button.
Adjust the other half of the button in the same manner. ‘The male half is pressed firmly into the female half, noting that all the
ft
eiges are turned in, Strengthen the union by a few Lembert sutures: Repair the rent in the mesentery and the anastomesis is complete (Fig. 429). It may be expected that the button will past about the
tenth day. Lateral Anastomosis.—Proceed as before, bringing out of the ale cavity the loops to be anastomosed and pack with sterihe
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TECHNIC OF LATERAL ANASTOMOSIS, s8r
compresses. Each loop is clamped and the two clamps laid side by side so as to bring about 5 inches of the bowel walls in contact (Fig. 430).
in this, case, use instead. Uinnie)
The first line of suture is to be applied nearer the convex thas the mesenteric border and should be about 3 inches in \engin. Yosee
582 ENTERECTOMY. INTESTINAL ANASTOMUSES.
the opposed surfaces then by a seroserous suture. ‘The fine of suture runs toward the operator, and when the line has reached, say 5 inches, the needle is left, still threaded, and temporarily laid aside.
‘The next step consists in making the openings which are to afford the means of communication between the two loops, A straight incision about 1/4 inch from and parallel with this line of suture lays open the bowel down to the mucosa. Section of these superficial enats leave exposed an ellipse of mucous membrane, and this ellipse sboubd be trimmed out with the scissors. The other loop is opened in the same way.
The adjoining edges are now to be coapted by continuous per
Pre 434 —Croas sectlen of laternt anastononia (itlamde)
forating suture (Fig. 431). As this suture progresses the opposite angle of the wound is reached, but without interruption it continors te draw together the mote widely separated borders (Fig. 432).
Wheo it has reached the point of beginning, the terminal thread is knotted with the first which was left long, and so the perforating suture is Gnished. Remove the clamps, wipe the bowel, and maw return to the sero-serous suture and continue with that until the per forating sutures are completely buried or, im other words, until the sero-scrous suture has traveled completely around the bowel and the terminal thread knotted with the primary suture:
Hf preferred, this sero-serous suture may be an interrupted instead of
@ continuous stitch (Fig, 433), bo\ Une conmiages suture is mene
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TECHNIC OF TRRMINO-LATERAL ANASTOMOSIS, 383
rapidly passed and fs in every respect as secure. ‘The main thing to be attained, however, is that the serous surfaces be brought Into contact through the whole circumference of the bowel,
Fig. 434 shows the appearance of the bowel on cross section after such an anastomosis. ‘This method may be modified in many ways,
Tio, 435.~Termino-tateral araxtormosis. Pro. 436—Termiog lateral champs Sid continuous ature emsiloyed y completed. Binnie) (Bimnte,)
‘but exemplifies really the fundamental principles involved in any anas- tomosis of the digestive tube, It is purposely stated in its simplest terms and shorn of detail.
The technic of the termino-lateral form of anastomosis does not differ in any essential detail from that just described for the latero- lateral form (Figs. 435 and 436).