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Acute Intestinal Obstruction
ACUTE INTESTINAL OBSTRUCTION CLARENCE DENNIS, M.D., PH.D.*
In many quarters, acute complete bowel obstruction is considered rare. An estimate of the frequency with which it is seen in the 450 beds at the University of Minnesota Hospitals suggests that one new small bowel obstruction is seen on the average once each two weeks10 and one new colon obstruction about once a month. 7 This is perhaps a higher incidence than might be expected, but Dr. O. H. Wangensteen has stimulated much wholesome interest in this subject, as in many others, in our community, and therefore more cases are recognized and referred to his service here than would otherwise be the case. Of all cases of cancer of the colon coming to the University of Minnesota Hospitals in 1938 to 1944, 9.5 per cent presented themselves with acute complete obstruction. Review of several series of cases has led to the conviction that a la,rge share of our failures in the therapy of bowel obstruction may be attributed to inaccurate diagnosis. The precise differentiation of colic from ileac obstruction, of paralytic ileus from mechanical obstruction, of strangulating from simple bowel obstruction, of high from low ileac obstruction, must precede consistently &lccessful management. In the past fifteen years, Wangensteen and his associates here, and later others in various quarters, have demonstrated the possibility of successful separation of the cases of small bowel obstruction amenable to nonoperative intubation-decompression therapy in a high percentage of cases. The appearance of strangulating lesions which were not diagnosed before surgery, and which in retrospect presented no clues which might have suggested the presence of strangulation, proved disturbing to our entire group. The .development of the Wangensteen aseptic decompressive enterotomy for evacuation of the distended bowel without contamination has provided the means to facilitate early operative intervention in almost all cases of intestinal obstruction regardless of the degree of distention. The recognition of the type and level of obstruction has thus become less imperative perhaps than earlier, in the choice of operative as against nonoperative management, but it is no less important in the decision as to the placement and type of incision to be employed and as to the urgency with which preparation and intervention are dictated. These diagnostic matters have been amply discussed elseFrom the Department of Surgery, University of Minnesota School of Medical Sciences, and the Minneapolis General Hospital. The investigative work outlined in this.chapter was supported by research grants from the Graduate School of the University of Minnesota. * Professor of Surgery, University of Minnesota School of Medical ~ciences and University of Minnesota Hospitals; Assistant Chief of Surgery, Minneapolis General Hospital. 13g7
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where ,4 , 10, 16 and the available space will be used in preference for the representation of certain technics. MECHANISMS OF OBSTRUCTION
A review of several years' experience at this clinic has given in broad outline the underlying mechanisms and the relative frequency thereof. In obstructions between the ligament of Treitz and the ileocecal junction, external hernias account for about 40 per cent and adhesions and bands about 50 per cent. In most years, all other mechanisms comprise only 10 per cent. These include volvulus, intussusception, gallstone obstruction, internal hernia, neoplasm and others. About 35 to 40 per cent of small bowel obstructions could well be treated by nonsurgical means, if we could but select the proper cases with unfailing accuracy. In the colon, primary carcinoma has accounted for two-thirds of our obstructions, and of these, six out of seven have involved the left colon. Half the remainder have been due to sigmoid volvulus. Other mechanisms include diverticulitis, other pelvic infection, secondary neoplasms, and adhesions. MECHANISMS OF DEATH IN UNTREATED CASES
A full appreciation of the available therapeutic measures must be predicated upon an awareness of the lethal factors in the several types of obstruction, Strangulation obstruction, whether volvulus of the cecum or sigmoid, or some type of ileac involvement, may kill by sufficient engorgement to lead, in conjunction with vomiting, to drastic reduction of blood volume and death in shock. Failing this, it may kill by perforation and peritonitis, or by sepsis if the necrotic bowel should be enclosed, as in a hernia sac or in intussusception. In the small gut, obstructions high in the ileum or in the jejunum lead to excessive vomiting of fluid containing most of the salivary, gastric, biliary, pancreatic and duodenal secretions-a total of 5 to 12 liters a day. Rapid dehydration, acute chloride loss and secondary uremia are rapidly fatal, if not corrected. If the block is low in the ileum, most of this fluid is reabsorbed, and chemical imbalances are relatively unimportant. Here, however, the concensus is that lethal transperitoneal absorption of toxic bacterial products may result from mucosal damage due to vascular impairment, which in turn is secondary to prolonged distention. In the colon, the process which kills, except occasionally in volvulus, is tension perforation and peritonitis. Although this rarely does occur at the obstructing carcinoma, the vast majority of reported cases have perforated at the cecum. Competence of the ileocecal valve, which renders the colon a closed loop, with ever rising pressure due to continued discharge of material from the ileum, leads to tension ischemia of the anterior cecal wall, the thinnest area and the largest in diameter. Incompetence of the valve, however, is no guarantee against cecal perforation.
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DIAGNOSTIC CONSIDERATIONS
Complete small bowel obstruction is characterized by persistent vomiting, which becomes fecal in character in three to five days.6 There are also regularly acute increases in abdominal pain (cramps) which come every three to ten minutes except in very late cases. Characteristically these cramps are associated with abdominal sounds of pitch higher than high C (or 512 per sec.). The degree of distention depends on the level of
Fig. 513.-Roentgen picture of abdomen of a patient with complete obstruction in the pelvic colon. In this case the ileocecal valve has prevented regurgitation into the ileum, and true "closed loop" obstruction is present. (From Wangensteen, O. H., Intestinal Obstructions, Ed. 2, Springfield, Ill., Charles C Thomas, 1948.)
the obstruction, being greater in the lower ones. X-ray signs are discussed elsewhere. 4 Recognition of strangulation must be early to be helpful if one is to treat any cases by nonsurgical measures. The findings, anyone of which is indicative of strangulation, are: history of sudden onset, back pain, shock, leukocytosis, fever, and signs of peritoneal irritation such as spasm and rebound tenderness. X-ray findings suggestive of a double coffee
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bean appearance should be viewed with suspicion of strangulation. With our recent adoption of exploration of nearly all cases of small bowel obstruction, early recognition of strangulation has assumed less importance, although it may indicate particular urgency in some cases. In colic obstruction, most cases result from carcinoma primary in the colic wall. Here a history may be obtained of gradually increasing constipation, perhaps alternating with diarrhea, of black or bloody stools, of weight loss over some months, of previous meteorism or even acute bouts of distention and obstruction, relenting after enemas. With acute
A
Fig. 514.-Examples of varying amounts of gas visible in the small bowel in cases of colic obstruction. Scout film of the abdomen. A, Gas visible in the ileum but in insufficient amount to produce definite distention (29 per cent of series). B, Definite small bowel distention, but colic distention predominant (32 per cent of series). (From Surgery, Vol. 15,7.)
obstruction from any cause, initial vomiting is the rule, but only half vomit more than two or at most three times, in contrast to the situation in ileac obstruction. Fecal vomiting is rarely seen in colic obstruction (8 per cent) ;1 it is a result of the length of time material has been in the bowel rather than the level in question. In colic obstruction, peristaltic rushes and cramps come at intervals of more than ten minutes, often hours or half-days. Clinical distention may be marked in lesions of the left colon but may be virtually absent in the trea.cherous right colic obstructions with competent ileocecal valve. It is in colic obstructions that x-ray evidence has proved most helpful. In a six year review of colic obstructions at this clinic in 1944,7 an effort
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was made to clarify the x-ray findings. Of forty-one cases of acute colic obstruction, thirteen (31.7 per cent) presented no x-ray evidence of gas in the ileum and of classical marked colic distention (Fig. 513). Twelve (29.3 per cent) 'showed just discernible gas in the ileum (Fig. 514A). Thirteen (31.7 per cent) showed definite distention of the small intestine (Fig. 514, B). Three (7.3 per cent) showed distention most marked
Fig. 515.-Example of varying amounts of gas visible in the small bowel in cases of colic obstruction. Scout film of the abdomen. Small bowel distention more marked than colic distention (7 per cent of series). (From Surgery, Vol. 15.)
in the ileum (Fig. 515), and presented a clinical picture in two of the cases which could easily be confused with small bowel obstruction. It is apparent, therefore, that about two-thirds of these cases presented diagnostically conclusive x-ray evidence of colic obstruction and that careful evaluation of the history and physical findings were in addition essential in the others. The lesions of the right colon are most prone to be accompanied by excessive vomiting and marked x-ray evidence of ileac distention.
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PREPARATION FOR SURGERY
The obstructed patient shows greater or less dehydration, depending on the level of the lesion. Reasonable evaluation of the degree is possible through hematocrit determinations. Chemical status can best be established by determinations of plasma protein level, plasma chloride level, blood urea nitrogen and carbon dioxide combining power. In general, the patient showing clinical dehydration may be assumed to have lost 5 to 7 per cent of his body weight, and the amount of water administered intravenously in the first twenty-four hours should be about 7 per cent of his body weight. Half of this infusion should be given in the two or three hours before surgery, the rest at a rate not exceeding 400 cc. an hour and preferably spread over the full twenty-four hours, to minimize the danger of pulmonary edema. Hypochloremia can be corrected according to Coller's rule 3-namely, that the number of grams of sodium chloride to be administered to restore the normal plasma chloride level is : 560 -
Plasma chloride (as mg. per lOOcc. NaCl) X B d ,. ht (k ) 200. 0 Y V\elg g.
A somewhat smaller amount is usually sufficient. Until the plasma chloride level has been reported, hydration can be nicely initiated by starting intravenous infusion of a mixture of equal parts of 5 per cent dextrose in distilled water and 0.9 per cent sodium chloride solution. In most instances hydration and chlorination can be completed with this mixture. It is noteworthy that obstructing lesions of the right colon usually produce marked small bowel distention. It is of paramount importance that cases of apparent ileac obstruction be carefully scrutinized to determine whether there is cecal distention, for right colic cases fall even ahead of left colic and strangulating ileac lesions as the most acute and treacherous emergencies in the bowel obstruction field. Depletion of serum protein level is a serious problem, and restoration of advanced cases to 6 gm. per 100 cc. by transfusions of blood or plasma before emergency surgery is not likely to be possible. It should, nevertheless, be attempted. It is only in those small bowel cases not presenting signs of strangulation that depletion below 6 gm. per 100 cc. should dictate a day or two of delay for replenishment by transfusion. In all other cases of acute complete obstruction of ileum or colon, the risks of delay are greater than those of immediate surgery with vigorous use of plasma or blood before, during and after operation. SURGICAL TECHNICS
No attempt will be made here to cover completely the procedures which may be employed. Rather, certain of them will be presented which have proved themselves of particular value in the past few years. For incarcerated or strangulating hernia repairs in poorly prepared patients, more satisfactory and safe anesthesia may be obtained by novo-
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cain block than by either spinal or general methods. In other instances the policy at the University Hospitals has been to use cyclopropane and oxygen administered through a tracheal tube by a closed system machine; supplementation with curare by the intravenous route has simplified matters immensely. Most important, a good anesthetist in attendance widens the range of surgical possibilities, Placement of a No. 17 or No. 15 needle for intravenous infusion into the cubital vein at the elbow offers a large degree of security, especially if cross matched blood is present in the operating room. Aside from hernioplasties, most emergency operations for intestinal obstruction are exploratory in that the site of the block in the abdomen is unknown. Longitudinal or oblique incisions are, therefore, to be preferred in ileac obstruction, as they provide wider possibilities of extension and exploration. The right midrectus is very satisfactory. Closure of the abdominal wall is most safely made with interrupted fine silk sutures of 3 or 4 pound tensile strength. Most of these patients may then safely be ambulatory the day after surgery, a measure which seems to have simplified the postoperative course immensely. In transverse colostomy a transverse incision is essential to regular success. Wangensteen nasal suction tubes are placed in the stomach prior to surgery unless the case has been treated conservatively long enough already to have a Wild tube down.17 Suction is maintained throughout the sojourn in the operating room and postoperatively until sounds are normal and gas is passed by rectum, in the ileac obstructions, or by colostomy in the colic obstructions. This usually occurs two to three days after surgery. Nutrition by the intravenous route is continued in these cases until oral feedings are possible. Aseptic Decompression.-Wangensteen has described a method of aseptic decompressive enterotomy15 for dealing with marked ileac distention which permits safe exploration where indicated regardless of that distention. The author has used the method with slight modifications in some two dozen cases, with entire satisfaction as to relief of distention without peritoneal contamination. 4 In many cases it would have been utterly impossible to deal successfully with the obstructive mechanism if preliminary decompression of the fragile, thin walled bowel had not first been accomplished. Use of Wangensteen's aseptic suction enterotomy as modified in this series of cases may be performed with the set supplied by V. Mueller and Company or with equipment to be found in any well supplied operating room (Fig. 516). The essentials consist of an ordinary empyema trocar, a soft rubber catheter large enough just to pass through the trocar, a long piece of Penrose drain, connecting tubing, a Wangensteen suction set, and sterile glycerin. Secure ridges for provision of anchorage of the bowel to the trocar may be formed by sliding three 2 or 3 mm. segments of heavy snug-fitting rubber tubing onto the end of the trocar before autoclaving. The heat of sterilizing seals them securely. As indicated in Figure 516, a piece of Penrose drain is tied on the sidearm of the trocar and
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Fig. 516.-Modified Wangensteen aseptic decompressive suction enterotomy. A, Method of emptying a distended segment of small bowel preparatory to enterotomy. The segment so emptied between the fingers should be 25-30 cm. long. Application of the rubber-shod Scudder clamps should be as light as possible as more trouble with adhesions arise from this site than from suture lines. B, Placement of a double purse string to secure the bowel to the trocar. Atraumatic ()() catgut is used. After placement of the purse strin~s, a 1 cm. incision in
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covers the entire external length of the catheter, being tied securely over a glass connector in the back end of the catheter. A half ounce of glycerin inside the soft rubber drain serves as lubricant. A second piece of Penrose drain is tied around the handle of the plunger of the trocar to avoid leakage from that source. A long segment of tubing connects the catheter to a Wangensteen suction set. About twelve holes, each 3 mm. in diameter, are cut in the last 6 cm. of the catheter. In using the apparatus, the most distended free segment is delivered cautiously and milked empty between the second and third fingers of the two hands of the surgeon, and Scudder clamps are very gently applied to keep that segment empty. This maneuver allows contraction of the muscle layers and consequent thickening of the bowel wall so that a firm bite may be obtained for sutures without the danger of leakage through the paper thin walls present before emptying. A purse string of No. 00 catgut on an atraumatic needle is laid, the purse string being 15 to 20 mm. in diameter. A second purse string laid 3 mm. wide of the first is extremely effective in eliminating leakage later. A transverse incision 1 cm. long down to the mucosa is made in the center of the purse strings, and the end of the trocar is secured to the bowel by tight tying of the catgut strands. Greater security is afforded by tying each end over the sidearm of the trocar. Suction is first applied, and then the plunger of the trocar is used to perforate the mucosa and then drawn back. The catheter can now be inserted into the bowel, and the Scudder clamps removed. the center exposes the intact mucosa so that easy perforation will be possible with the plunger point. e, Securing of trocar. As an added precaution against leakage, the ends of the double purse string are tied over the side arm of the trocar. Following perforation of the mucosa, the plunger is withdrawn and the catheter is slipped into the bowel. Soiling is prevented by protection of both the plunger shaft and the catheter by soft rubber drains, lubricated with glycerin. D, Suction decompression. Very gentle lifting of the segments of bowel will direct content to the catheter. The entire small bowel can be emptied by this means, particularly if a 3 foot catheter is employed. E, Clean removal of the trocar. A transverse row of interrupted Lembert sutures is preplaced and held up with hemostats in such manner as to support the bowel. The catheter is withdrawn into the trocar, but suction is maintained. A No. 11 Bard-Parker blade cuts the two purse strings, and the trocar and attachements are placed cleanly into a large basin placed for the purpose immediately beside the bowel. F, Closure of the defect. Traction on the ends of the preplaced Lembert sutures apposes the serosa without soiling. G, Completion of closure. Closure may be reinforced by a second row of silkHalsted mattress sutures, and 30 mg. of sulfanilamide powder may be implanted between the rows. Recently the second layer of sutures and the sulfonamide have been discarded as unnecessary. The closure process may be eliminated altogether in strangulation if a segment is employed close enought to the necrotic bowel to permit block excision of the entire area-with immediate anastomosis. (Modified from Wangensteen's Intestinal Obstructions by permission of the author and Charles C Thomas, publisher. Reprinted by permission of W. H. Cole and Appleton Century Co. from Cole's "Operative Technique," 1949.)
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It is now practicable to empty the entire small bowel above the site of obstruction by very gentle threading of the catheter through the bowel in both directions and by gentle elevation of the fluid filled loops to lead fluid to the catheter. Direction of attention to the obstructing mechanism is in order only after rather complete ileac evacuation. The danger of accidental tearing of the bowel wall is then minimized, and spillage in event of accident is absent or minimal. In some instances it will be found that strangulation has rendered a segment nonviable. In such cases it simplifies the procedure to have placed the trocar close to this area, enabling the surgeon to resect both the gangrenous bowel and the trocar site in one segment. This is usually accomplished by selection of the most distended loop, usually the lowest one, for decompression. If simple obstruction is found and relieved without resection, closure of the decompression site must be accomplished. To do this cleanly, an effective procedure is to preplace six to eight Lembert stitches in a transverse row in such fashion that tying after removal of the trocar will invert all the bowel involved in the purse strings and 0.5 cm. more on each side. After preplacement of the sutures, the catheter is withdrawn into the trocar, and the suction left in force. By traction on the catgut ties previously brought over the sidearm, each purse string can be visualized and divided with a No. 11 Bard-Parker knife blade. A discard basin held immediately adjacent to the bowel receives the trocar, and other instruments, with minimal chance for contamination. The Lembert sutures are tied, completing the closure. A second row of closure has been abandoned as unnecessary. The rather extensive inversion of tissue which occurs does not occlude the lumen because of the marked stretching of the bowel produced by preoperative distention. In no instance has clinical obstruction in the postoperative period been recognized. On a few occasions laparotomy for other lesions at a later time has made possible reexamination of this area. Except for the presence of suture, it is usually very difficult to differentiate this segment from others in the small intestine. Resection of Gangrenous Bowe1.-Experience at the University Hospitals has shown that resection with primary end-to-end anastomosis is a practicable and safe method of dealing with small bowel obstruction in which nonviable intestine is found. 6 The anastomosis recommended is a modification of that of Martzloff and Burget. One of the chief difficulties which this procedure is designed to overcome is the end-to-end union of segments of widely differing diameter without the formation of blind pockets or kinks. The mesentery is meticulously cleaned from the distended bowel proximal to the point of obstruction, a site close to the point of approach of large vessels in that mesentery being chosen (Fig. 517, 1). A slender, crushing, anastomosis clamp is placed across the bowel, from the antimesenteric border, at an angle of about 75 degrees from the long axis of
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the gut. The clamp crosses the mesenteric border about 6 mm. below the edge of the unremoved mesentery. In order to minimize the danger of spillage of any of the content of the distended bowel during the later stages of the procedure, the contents are cautiously milked back between the fingers for 10 or 20 cm. from the
Fig. 517.-1, Placement of the first anastomosis clamp on the distended bowel above the point of obstruction. The clamp crosses the bowel at an angle of 75 degrees and at the mesenteric border about 6 mm. fr.om the edge of the unremoved mesentery. The bowel has been milked back and a rubber shod clamp is applied to prevent spillage. 2, Placement of the second anastomosis clamp on the contracted bowel below the point of obstruction. The line of crush begins 6 mm. from the unremovedmesentery, crosses obliquetly two-thirds of the bowel and passes for a distnce parallel with the antimesenteric border before crossing the remaining one-third of the bowel. a, This length of crushed tissue, equal to that in 1, is obtained by distorting the bowel with Allis forceps. This clamp is placed from the mesenteric border. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
clamp, and a rubber shod intestinal clamp is lightly applied. This clamp remains in place until the completion of the anastomosis. Below the point of obstruction, the diameter of the bowel is usually one-third to one-half that above, and the anastomosis clamp must therefore be placed much more obliquely to attain a length of crushed tissue equal to that above. Most satisfactory ..tomas have been achieved by the application of the clamp from the mesenteric border with distortion of the bowel by Allis forceps lightly applied in such fashion that the line of
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crush, beginning at the mesenteric border, crosses obliquely two-thirds of the way to the antimesenteric border, then runs longitudinally down the bowel to gain the necessary length of crush before it crosses the remainder of the gut (Fig. 517,2, 2a). The cleaning of the mesentery and the placement of the clamp with regard to the cleaned area are accomplished as on the distended intestine. *
Fig. 518 -3, Cutting the bowel between the clamps described in Figure 517 with the cautery. To prevent spillage additional clamps are placed between those applied for anastomosis and the specimen to be removed. 4, Placement of the posterior running fine catgut suture. The clamps are held side by side, so that the bowel ends are brought together with 180 degrees' rotation of one with respect to the other. The suture is laid with the clamps rolled away from each other as shown. The bites are 5 mm. long and the gaps between bites are 4 mm. a, Placement of each end bite parallel with the long axis of the gut assures good inversion later. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
A similar clamp is placed between the bowel to be resected and each of the clamps already described, a 3 or 4 mm. gap us~ally being left be-
* The value of this type of placement is not limited to anastomoses performed in the presence of obstruction. In the terminal ileum under normal conditions the lumen is small enough to render anastomosis without undue reduction of the lumen difficult. This type of placement of clamps with 180 degrees' rotation has proved uniformly successful under these circumstances. In other sites where bowel ends of unequal diameter are to be joined, such a's in end-to-end ileocolostomy after right hemicolectomy, this type of anastomosis has also proved uniformly successful.
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tween clamps. The intestine is cut in the gap between each of these pairs of clamps with the actual cautery (Fig. 518, 3). The anstomosis clamps are laid side by side, thus bringing the bowel ends together with one end rotated 180 degrees with respect to the other about the long axis of the gut (Fig. 518,4). Ideally the length of the area of crush in the two clamps is identical, for by this precaution the most accurate apposition of the two ends can be attained in making the anastomosis. The clamps are rotated away from each other, and a running bast-
Fig. 519.-5, Placement of the anterior running catgut suture. The clamps have been rolled together. 6, Removal of clamps. Tension is applied to the two ends of each of the running sutures, the clamps are carefully loosened until the tips are spread 1 or 2 mm. and the clamps are cautiously and simultaneously removed. ~From Surgery, Gynecology and Obstetrics, Vol. 77.)
ing stitch of No. 00 or No. 000 plain catgut on an atraumatic needle is placed posteriorly, about 5 mm. being taken in each bite, with a slightly smaller gap (4 mm.) being left between bites. Subsequent inversion occurs spontaneously at the time of withdrawal of the clamps only if the ends of the running sutures are properly placed; inversion of the corners with instruments, which invites contamination, may thus be avoided. Each end bite of each suture must be about 5 or 6 mm. long and parallel with the axis of the bowel, and should emerge close to the clamp (Fig. 518,4a).
The anastomosis clamps are now rolled together, and a similar running stitch is placed anteriorly (Fig. 519, 5).
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Tension is applied to the two ends of each of the basting sutures, the clamps are carefully loosened until the tips are spread 1 or 2 mIll., and the clamps are cautiously and simultaneously withdrawn (Fig. 519, 6). If the sutures have been properly placed, inversion of the cut ends of intestine will occur with no further manipulation, and clean serosal approximation will result. Tension is maintained on the basting stitches while the ends of the posterior strand are tied to the corresponding ends of the anterior strand.
Fig. 520.-8, Tying of the Halsted mattress sutures, with maintenance of tension on catgut strands. The posterior side is treated in similar fashion. 9, Rear view of anastomosis, showing placement of stitch to close the mesenteric defect. (From Surgery Gynecology and Obstetrics, Vol. 77.)
With maintenance of tension on the ends of the basting stitches throughout, interrupted Halsted mattress sutures of 2.5 pound test silk or cotton are laid anteriorly, and the mattress sutures are tied just tightly enough for snug apposition (Fig. 520,8). The bowel is rolled over, and the posterior closure is similarly reinforced, tension being continued to this point on the ends of the catgut strands. Tension on the basting sutures is gradually lessened as the stoma is broken down by inverting the bowel below the anastomosis with a thumb or two fingers and thus pushing through the stoma. The catgut basting stitch, which is circular by virtue of the knots at the ends of the suture line, is held taut by this device while inversion Halsted mattress sutures are placed at the ends. The
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catgut ends are cut just inside the knots on one end and withdrawn altogether. They have served to hold the bowel for placement of the silk sutures, and the removal of them leaves a one layer silk anastomosis, thus free of the delay in mucosal healing resulting from continued presence of the catgut. To close the mesenteric defect, a stitch near the center of the posterior suture line is threaded on a needle and a small bite of each mesenteric edge is taken 3 cm. from the bowel (Fig. 520, 9), and behind it, and thus the defect in the mesentery is tied. From this point to the root of the
4~m.},
A"::W 3mm.
eM.
Fig. 521.-The anastomosis clamp 9. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
mesentery, interrupted silk sutures are placed. Efforts to cover the suture line with omentum have been abandoned as useless. The clamps used in maki:ng this anstomosis differ from those of Martzloff and Burget in that they are shorter. and lighter. * With the shorter clamp one may rely less on the springiness of the instrument to crush the tissue at the tip, and the clamps may therefore be more easily removed during the anastom~sis. Deep, sharp, longitudinal, matching grooves are cut on the jaws of the clamp (Fig. 521). The advantages of this type of anastomosis over many of those described in the literature are as follows: 1. End-to-end anastomosis avoids the formation of the blind pouches
* Clamps can be obtained from V.
Mueller Company, Chicago.
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which result from closure of both ends and side-to-side anastomosis (Fig. 522). 2. End-to-end anastomosis necessitates but one suture line, whereas closure of the ends and side-to-side anastomosis requires three lines. 3. Aseptic procedure permits apposition of serosal surfaces uncontaminated with luminal contents, a point heavily supported by experimental work. 4. Obliquity of placement of clamps permits the best possible blood supply to the line of suture, for the vessels follow a circular course around the bowel and are not, therefore, interfered with before reaching the suture line.
a'
b'
Fig. 522.-a, Schematic drawing to illustrate the angulation resulting from endto-end anastomosis for bowel cut at 45 degrees and apposed without rotation. b, The obviation of angulation accomplished by rotation of one segment with respect to the other is apparent. (Reprinted from Surgery, Vol. 5.)
5. Rotation of one segment of bowel with respect to the other minimizes angulation and therefore minimizes possibility of obstruction at the point of anastomosis, as shown in Figure 522. 6. Rotation of the bowel avoids the dangers of closure without peritoneum at the mesenteric border; in other words, by this rotation peritoneum is provided on one surface or the other completely around the line of inversion. * 7. This type of anastomosis avoids the danger of stenosis at any time in the postoperative period. There has been no case of dysfunction secondary to the quarter twist imposed on each end to be anastomosed. Use of this or the Martzloff-Burget anastomosis should not be
* In over sixty clinical cases and sixty experimental anastomoses, no instance of leakage at the ends of .the suture line, i.e., at the mesenteric border on one side, has occurred. In one case leakage has occurred in the midportion, but here the peritoneum was found contaminated with feces when the abdomen was first opened.
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Fig. 523.-Closed, one-layer, interrupted silk anastomosis. a, Placement of first Halsted mattress sutures. Note that the clamps are placed not quite completely across the bowel. The point of exit of sutures closest to the modified Martzloff clamp is 7 mm. from the cut edge of the bowel. If the bowel is less than 2 em. in diameter, either smaller clamps may be used, or the sutures may be placed immediately adjacent to the clamps and the clamps removed before tying the stitches, or, preferably, the two layer, oblique, end-to-end anastomosis may be used, best with withdrawal of the inner catgut basting stitch after completion of the silk suture line. When the distance from the cut edge of the bowel to the . stitches is more than one-third the length of tissue along the crushing clamps, real danger of obstruction is present. b, Completion of back side of anastomosis, tying also over ends of clamps. c, and d, Front side of anastomosis. e, Removal of clamps-delayed until all but two sutures have been tied. j, Completion of anastomosis by tying last two sutures after removal of clamps. The total number of sutures for intestinal anastomosis has varied from 11 to 18. (From Annals of Surgery, Vol. 126.)
attempted by those unfamiliar with intestinal suture until some experience has been gained in the dog. Difficulties may arise from improper placement of the catgut suture, tearing of the friable distended bowel by
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CLARENCE DENNIS
use of heavy instruments or too heavy sutures, and postoperative adhesion formation at the site of placement of the Scudder clamps. There is no need to resect bowel because it is distended or because it fails to contract on stimulation by snapping with the finger, or because it does not offer normal resistance to placing the needle. The greatest gentleness will be rewarded by absence of postoperative cramps or obstruction. In infants in whom intussusceptions prove irreducible or frankly gangrenous, resection is essential. Gross and Ware have reported a method in which a temporary double barreled ileostomy or ileocolostomy is closed after three to four days.12 His is an enviable record, and the first to be presented with low mortality. To the author it has seemed more. direct and neater to do a primary closed anastomosis. Here both the upper and lower segments are large in diameter, and the anastomosis may be done over narrow anastomosis clamps without the temporary use of catgut (Fig. 523). Much discussion centers about the choice of closed as against open anastomosis. Where good preparation of the bowel is possible, it does not make much difference which is used. In obstruction cases this is not true, and comparison of open as against closed anastomosis series, both in the laboratory and clinically, shows that the results have been distinctly better where serosal contamination has been minimized by closed anastomosis. 9 Femoral Hernia with Gangrenous Bowel.ll-Under local block anesthesia, a vertical incision is made over the bulge in the groin and carried cautiously down to the peritoneal sac. The contents of the sac can be visualized through the remaining wall; bloody fluid, pus, feces, or black bowel can usually be readily recognized (Fig. 524, a). In case any of these indicates the presence of gangrenous bowel, dissection in this area is discontinued, and an incision is made 2 cm. above the inguinal ligament and parallel to it, and the vertical incision is continued upward to it to make a T-shaped incision (Fig. 524, b). The aponeurosis of the external oblique muscle is split parallel to the ligament and about 1 cm. above it, and extended into the external inguinal ring. The margins of the internal oblique and transversus muscles (and the cord if the patient is male) are elevated, the deep epigastric vessels are divided and ligated, and the peritoneum is incised parallel with the oblique skin incision. From this vantage point, the viscera entering the hernia may be easily seen. Omentum, if involved, is easily divided and ligated close to the neck. The small bowel entering the sac is prepared by division of the mesenteric attachment from the proximal to the distal side of the incarcerated loop of bowel. Two Ochsner clamps are placed across each of these limbs of bowel, and the ileum is severed between each pair with the cautery. After the gangrenous sac contents have been freed from intra-abdominal attachments, the inguinal ligament is divided close to the pubic attachment and split laterally, leaving enough heavy aponeurotic tissue
ACUTE INTESTINAL OBSTRUCTION
1415
applied to the front of the neck of the sac to prevent relaxation of the neck and release of the soiled content. The sac is encased in a rather firm layer of fascia derived from the femoral canal. Dissection outside it frees the entire sac except for the residual fibrous portions of the ring, which can then be cut under direct vision from the surrounding tissues and left on the neck of the sac (Fig. 525). Palpation for an anomalous obturator artery adds an item of safety here. The entire contaminated area may then be removed intact, without soiling of the remaining field. Further preparation of the remaining bowel ends may then be done easily, and oblique, aseptic end-to-end anastomosis is performed as for
Fig. 524.-Femoral hernia with gangrenous bowel. Skin incision: a, for recognition of gangrene, without opening sac; b, completion of incision after recognition of gangrene. (From Surgery, Vol. 22.)
any case of resection in the presence of obstruction. Following closure of the mesentery, the bowel is dropped back into the abdomen. Performance of the anastomosis is facilitated by placement of the posterior silk row as interrupted Cushing stitches before use of the running catgut. Closure of the peritoneal defect in the repair of the hernia is easily accomplished because of the usual mobility of the peritoneum in this area. Closure is usually made by interrupted mattress sutures of 2 pound test silk, approximating the margins of the defect resulting from excision of the sac in a vertical line and closing the original oblique peritoneal incision in a line parallel with the original opening. Repair of the hernial and surgical defect is simplified by application of the prinpiples of the McVay-Harkins modification of the Lotheisen hernioplasty. The margins of the internal oblique and transverse muscles are sutured to Cooper's ligament as far laterally as the femoral vein and
1416
CLARENCE DENNIS
to the inguinal ligament lateral to that point (the cord in the male ordinarily being left external to this layer). A McVay-Harkins relaxing incision may be made in the posterior layer of the anterior rectus sheath if needed to gain approximation without tension. The inguinal ligament is restored easily by interrupted sutures of 3 pound test silk, approximating it as far medially as it will go without undue tension, to the lacunar ligament and to Cooper's ligament.
Fig. 525.-Femoral hernia with gangrenous bowel. Separation of neck of sac with retention of intact fibrous ring. (From Surgery, Vol. 22.)
The aponeurosis of the external oblique muscle is finally approximated with interrupted silk (over the cord in the male), completing the hernial repair proper. Silk closure of the skin is used without drainage. If no evidence of necrosis is apparent upon first exposure of the sac, it is well to dissect the sac rather widely and to place moist packs about it before incision of the sac wall. In case no nonviable bowel is encountered, the sac, of course, may be widely opened, the hernia reduced by enlarging the neck medially, and the repair done entirely from below.
ACUTE INTESTINAL OBSTRUCTION
1417
Transverse Colostomy.-Although the possibility of primary surgery upon obstructing colic lesions appeals to the imagination, experience has shown that the risk is more than twice as great as that of preliminary decompression followed by resection after recovery from distention. These results are considered due to edema and poor circulation in the thinned and stretched bowel wall, combined with actual bacterial invasion from the lumen. Only after these changes have been corrected by recovery after decompression, has surgery to the lesion itself proved feasible. Decompression of the distended colon seen in acute obstruction is to be regarded as a surgical emergency. Among most surgeons, cecostomy has long been considered the procedure of choice for decompression of the distended colon. Because of the impossibility of really aseptic decompression by cecostomy and the difficulty of complete delivery of the cecum in the presence of marked distention, the mortality is high in that procedure; Wangensteen states that the mortality associated with this operation at the University of Minnesota Hospitals was nearly 50 per cent, a figure corroborated by CampbelP and others. Several years ago, Wangensteen suggested that decompression in acute left colic obstruction be accomplished by transverse colostomy.l6 He emphasized that the incision could be precisely placed over the distended transverse colon to be exteriorized if a preliminary scout film with a coin on the umbilicus was made (Fig. 526). This is a sound precautionary measure. Wangensteen particularly emphasizes in his teaching at the clinic here that this procedure must be done through a transverse incision, preferably cutting across the right rectus muscle halfway between the umbilicus and the xyphoid. Patients have been referred to this hospital after attempts to accomplish decompression of the transverse colon through vertical abdominal incisions, and this procedure has failed because of inability to deliver the distended transverse colon through such an incision. Decompression of the bowel intraperitoneally in order to facilitate delivery through a vertical incision invites the hazards of cecostomy. Such decompression prior to delivery is almost never necessary after entry through a properly placed transverse incision. In performing transverse colostomy, the colon is elevated over one or two glass rods and further fixed by fine silk sutures securing the omentum and fatty tags to the peritoneum and rectus sheath (Wangensteen). In the presence of distention, no sutures are placed in the bowel wall proper. Massive petrolatum dressings are placed to cover all the field but a small area of the bowel before insertion of a hypodermic needle for decompression. If the bowel refills quickly, it is aspirated every few hours during the next two days; at that time a 6 cm. longitudinal anterior cut is made with the cautel'Y. The glass rods are removed at ten days. This procedure accomplishes complete deviation of the fecal stream, a matter of some i.mportance in subsequent surgical procedures. Primary Resection of Right Colic Obstructing Cancers.-In obstructing cancers of the right colon, the problem is simplified because the asep-
1418
CLARENCE DENNIS
tic decompression maneuver may easily be applied at the terminal ileum, with decompression of the colon by passage of the catheter through the ileocecal valve, followed by immediate right hemicolectomy with primary closed ileotransverse colic anastomosis. Such a plan has been used five times without incident, with uniform recovery, and with early dismissal from the hospital. One would expect better long term results because of
Fig. 526.-Technic of decompressing the distended colon. Sketch of a radiogram from a case. A five-cent piece is taped over the umbilicus. In the insert, on the left, the actual size of the nickel drawn to scale is shown in a. The 33 per cent enlargement on the anterior abdominal wall is shown in b. The intestinal coils within the abdomen are enlarged 25 per cent. In the insert on the right, the method of deflating the colon on completion of the operation is shown. After a few such aspirations, the bowel is incised and a tube is inserted before it is finally cut for 6 em. longitudinally. The tension in the bowel is determined before its contents are aspirated. (From Wangensteen, O. H., Intestinal Obstructions, Ed. 2, Springfield, Ill., Charcles C Thomas, 1948.)
earlier removal of the offending carcinoma, but no data are available on this point. Reduction of Volvulus of the Sigmoid Colon.-Dr. Christian Bruusgaard of Ullevaal Hospital, Oslo, Norway, recently spent a year with us at Dr. Waagensteen's clinic. His report of proctoscopic deflation of the distended sigmoid involved in torsion l was supplemented by repeated demonstrations of the efficacy and safety of the method. In patients suffering volvulus of the sigmoid colon, in whom no evi-
ACUTE INTESTINAL OBSTRUCTION
1419
dences of impaired viability are present, insertion of a proctoscope until the spiraling folds of mucosa can be seen (at from 15 to 25 cm.) facilitates the passage of a soft rectal tube into the distended sigmoid loop. The brisk escape of gas and liquid heralds a successful result. As Bruusgaard and Wangensteen demonstrated, elective primary sigmoid resection some two weeks later safel¥ relieves the patient of the high risk of recurrence. In event of evidences of loss of viability, laparotomy with exteriorization of the sigmoid loop is essential and may be followed by later closure of the resultant double-barrelled colostomy. CONCLUSION
An absolutel¥ essential factor to the consistently successful management of bowel obstruction is accurate diagnosis. Patients with badly depleted nutritional status may have surgery for acute complete bowel obstruction deferred only if signs indicate the process to be a simple small bowel lesion. Right complete colic obstructions appear to present the most acute surgical emergency in the whole obstruction field, with left colic and strangulating small bowel lesions sharing second place. With the advent of the Wangensteen aseptic decompression technic the era of routine nonoperative management has passed, and the well trained surgeon is safest to explore all cases of bowel obstruction. The small bowel and right colic lesions are best explored through a vertical or oblique incision; in left colic obstructions a right upper transverse incision is recommended for transverse colostomy. More direct technics have reduced the risks in strangulating hernias, in marked distention, in right colic obstruction, in intussusception, and in volvulus of the sigmoid colon. Despite these technics, progress can be expected only by careful attention to water and salt balance as Coller and his group have stressed, and to the protein metabolism of these usually debilitated patients. REFERENCES 1. Bruusgaard, C.: Volvulus of the Sigmoid Colon and Its Treatment. Surgery 22: 466, 1947. 2. Campbell, O. J.: Surgery of Carcinoma of the Colon. Minnesota Med. 23: 215, 1940. 3. Coller, F. A. and Maddock, W. B.: Water and Electrolyte Balance. Surg., Gynec. & Obst. 70: 340, 1940. 4. Dennis, C.: Surgery of the Small Intestine. In Operative Technique, Warren Cole, Editor. Appleton-Century, 1949. In press. 5. Dennis, C.: Oblique, Aseptic, End-to-end Intestinal Anastomosis. Surgery 5: 548, 1939. 6. Dennis, C.: Oblique, Aseptic, End-to-end Ileac Anastomosis, Procedure of Choice in Strangulating Small Bowel Obstruction. Surg., Gynec. & Obst. 77: 225, 1943. 7. Dennis, C.: Treatment of Large Bowel Obstruction. Surgery 15: 713,1944.
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CLARENCE DENNIS
8. Dennis, C.: Resection and Primary Anastomosis in the Treatment of Gangrenous or Non-reducible Intussusceptions in Children. Ann. Surg. 126: 785,1947. 9. Dennis, C.: Some Considerations in Intestinal Anastomosis. Minnesota Med. 1949. In press. 10. Dennis, C. and Brown, Schuyler P.: Treatment of Small Bowel Obstruction; Procedure Used at the University of Minnesota Hospitals. Surgery 13: 94, 1943. 11. Dennis, C. and Varco, Richard L.: Femoral Hernia with Gangrenous Bowel Surgery 22: 312, 1947. 12. Gross, R. E. and Ware, P. F. Intussusception in Childhood; Experience in 610 Cases. New England J. Med. 239: 645,1948. 13. Martzhoff, K. H. and Burget, G. E.: Aseptic, End-to-end Anastomosis and a Method for Making Closed Intestinal Loops Suitable for Physiologic Studies. Arch. Surg. 23: 542,1931. 14. Wangensteen, O. H. Personal communications. 15. Wangensteen, O. H.: New Operative Techniques in the Management of Bowel Obstruction; Aseptic Decompressive Suction Enterotomy, Aseptic Enterotomy for Removal of Obstructing Gallstone, and Operative Correction of Non-rotation. Surg., Gynec. & Obst. 75: 675,1942. 16. Wangensteen, O. H.: Intestinal Obstructions. 2d Ed. Springfield, Ill., Charles C Thomas, 1948. 17. Wild, J. J.: The Design and Management of Long Intestinal Tubes. Surgery 25: 779, 1949.
In many quarters, acute complete bowel obstruction is considered rare. An estimate of the frequency with which it is seen in the 450 beds at the University of Minnesota Hospitals suggests that one new small bowel obstruction is seen on the average once each two weeks10 and one new colon obstruction about once a month. 7 This is perhaps a higher incidence than might be expected, but Dr. O. H. Wangensteen has stimulated much wholesome interest in this subject, as in many others, in our community, and therefore more cases are recognized and referred to his service here than would otherwise be the case. Of all cases of cancer of the colon coming to the University of Minnesota Hospitals in 1938 to 1944, 9.5 per cent presented themselves with acute complete obstruction. Review of several series of cases has led to the conviction that a la,rge share of our failures in the therapy of bowel obstruction may be attributed to inaccurate diagnosis. The precise differentiation of colic from ileac obstruction, of paralytic ileus from mechanical obstruction, of strangulating from simple bowel obstruction, of high from low ileac obstruction, must precede consistently &lccessful management. In the past fifteen years, Wangensteen and his associates here, and later others in various quarters, have demonstrated the possibility of successful separation of the cases of small bowel obstruction amenable to nonoperative intubation-decompression therapy in a high percentage of cases. The appearance of strangulating lesions which were not diagnosed before surgery, and which in retrospect presented no clues which might have suggested the presence of strangulation, proved disturbing to our entire group. The .development of the Wangensteen aseptic decompressive enterotomy for evacuation of the distended bowel without contamination has provided the means to facilitate early operative intervention in almost all cases of intestinal obstruction regardless of the degree of distention. The recognition of the type and level of obstruction has thus become less imperative perhaps than earlier, in the choice of operative as against nonoperative management, but it is no less important in the decision as to the placement and type of incision to be employed and as to the urgency with which preparation and intervention are dictated. These diagnostic matters have been amply discussed elseFrom the Department of Surgery, University of Minnesota School of Medical Sciences, and the Minneapolis General Hospital. The investigative work outlined in this.chapter was supported by research grants from the Graduate School of the University of Minnesota. * Professor of Surgery, University of Minnesota School of Medical ~ciences and University of Minnesota Hospitals; Assistant Chief of Surgery, Minneapolis General Hospital. 13g7
1398
CLARENCE DENNIS
where ,4 , 10, 16 and the available space will be used in preference for the representation of certain technics. MECHANISMS OF OBSTRUCTION
A review of several years' experience at this clinic has given in broad outline the underlying mechanisms and the relative frequency thereof. In obstructions between the ligament of Treitz and the ileocecal junction, external hernias account for about 40 per cent and adhesions and bands about 50 per cent. In most years, all other mechanisms comprise only 10 per cent. These include volvulus, intussusception, gallstone obstruction, internal hernia, neoplasm and others. About 35 to 40 per cent of small bowel obstructions could well be treated by nonsurgical means, if we could but select the proper cases with unfailing accuracy. In the colon, primary carcinoma has accounted for two-thirds of our obstructions, and of these, six out of seven have involved the left colon. Half the remainder have been due to sigmoid volvulus. Other mechanisms include diverticulitis, other pelvic infection, secondary neoplasms, and adhesions. MECHANISMS OF DEATH IN UNTREATED CASES
A full appreciation of the available therapeutic measures must be predicated upon an awareness of the lethal factors in the several types of obstruction, Strangulation obstruction, whether volvulus of the cecum or sigmoid, or some type of ileac involvement, may kill by sufficient engorgement to lead, in conjunction with vomiting, to drastic reduction of blood volume and death in shock. Failing this, it may kill by perforation and peritonitis, or by sepsis if the necrotic bowel should be enclosed, as in a hernia sac or in intussusception. In the small gut, obstructions high in the ileum or in the jejunum lead to excessive vomiting of fluid containing most of the salivary, gastric, biliary, pancreatic and duodenal secretions-a total of 5 to 12 liters a day. Rapid dehydration, acute chloride loss and secondary uremia are rapidly fatal, if not corrected. If the block is low in the ileum, most of this fluid is reabsorbed, and chemical imbalances are relatively unimportant. Here, however, the concensus is that lethal transperitoneal absorption of toxic bacterial products may result from mucosal damage due to vascular impairment, which in turn is secondary to prolonged distention. In the colon, the process which kills, except occasionally in volvulus, is tension perforation and peritonitis. Although this rarely does occur at the obstructing carcinoma, the vast majority of reported cases have perforated at the cecum. Competence of the ileocecal valve, which renders the colon a closed loop, with ever rising pressure due to continued discharge of material from the ileum, leads to tension ischemia of the anterior cecal wall, the thinnest area and the largest in diameter. Incompetence of the valve, however, is no guarantee against cecal perforation.
ACUTB INTESTINAL OBSTRUCTION
1399
DIAGNOSTIC CONSIDERATIONS
Complete small bowel obstruction is characterized by persistent vomiting, which becomes fecal in character in three to five days.6 There are also regularly acute increases in abdominal pain (cramps) which come every three to ten minutes except in very late cases. Characteristically these cramps are associated with abdominal sounds of pitch higher than high C (or 512 per sec.). The degree of distention depends on the level of
Fig. 513.-Roentgen picture of abdomen of a patient with complete obstruction in the pelvic colon. In this case the ileocecal valve has prevented regurgitation into the ileum, and true "closed loop" obstruction is present. (From Wangensteen, O. H., Intestinal Obstructions, Ed. 2, Springfield, Ill., Charles C Thomas, 1948.)
the obstruction, being greater in the lower ones. X-ray signs are discussed elsewhere. 4 Recognition of strangulation must be early to be helpful if one is to treat any cases by nonsurgical measures. The findings, anyone of which is indicative of strangulation, are: history of sudden onset, back pain, shock, leukocytosis, fever, and signs of peritoneal irritation such as spasm and rebound tenderness. X-ray findings suggestive of a double coffee
CLARENCE DENNIS
1400
bean appearance should be viewed with suspicion of strangulation. With our recent adoption of exploration of nearly all cases of small bowel obstruction, early recognition of strangulation has assumed less importance, although it may indicate particular urgency in some cases. In colic obstruction, most cases result from carcinoma primary in the colic wall. Here a history may be obtained of gradually increasing constipation, perhaps alternating with diarrhea, of black or bloody stools, of weight loss over some months, of previous meteorism or even acute bouts of distention and obstruction, relenting after enemas. With acute
A
Fig. 514.-Examples of varying amounts of gas visible in the small bowel in cases of colic obstruction. Scout film of the abdomen. A, Gas visible in the ileum but in insufficient amount to produce definite distention (29 per cent of series). B, Definite small bowel distention, but colic distention predominant (32 per cent of series). (From Surgery, Vol. 15,7.)
obstruction from any cause, initial vomiting is the rule, but only half vomit more than two or at most three times, in contrast to the situation in ileac obstruction. Fecal vomiting is rarely seen in colic obstruction (8 per cent) ;1 it is a result of the length of time material has been in the bowel rather than the level in question. In colic obstruction, peristaltic rushes and cramps come at intervals of more than ten minutes, often hours or half-days. Clinical distention may be marked in lesions of the left colon but may be virtually absent in the trea.cherous right colic obstructions with competent ileocecal valve. It is in colic obstructions that x-ray evidence has proved most helpful. In a six year review of colic obstructions at this clinic in 1944,7 an effort
ACUTE INTESTINAL OBSTRUOTION
1401
was made to clarify the x-ray findings. Of forty-one cases of acute colic obstruction, thirteen (31.7 per cent) presented no x-ray evidence of gas in the ileum and of classical marked colic distention (Fig. 513). Twelve (29.3 per cent) 'showed just discernible gas in the ileum (Fig. 514A). Thirteen (31.7 per cent) showed definite distention of the small intestine (Fig. 514, B). Three (7.3 per cent) showed distention most marked
Fig. 515.-Example of varying amounts of gas visible in the small bowel in cases of colic obstruction. Scout film of the abdomen. Small bowel distention more marked than colic distention (7 per cent of series). (From Surgery, Vol. 15.)
in the ileum (Fig. 515), and presented a clinical picture in two of the cases which could easily be confused with small bowel obstruction. It is apparent, therefore, that about two-thirds of these cases presented diagnostically conclusive x-ray evidence of colic obstruction and that careful evaluation of the history and physical findings were in addition essential in the others. The lesions of the right colon are most prone to be accompanied by excessive vomiting and marked x-ray evidence of ileac distention.
1402
CLARENCE m<';NlIiIS
PREPARATION FOR SURGERY
The obstructed patient shows greater or less dehydration, depending on the level of the lesion. Reasonable evaluation of the degree is possible through hematocrit determinations. Chemical status can best be established by determinations of plasma protein level, plasma chloride level, blood urea nitrogen and carbon dioxide combining power. In general, the patient showing clinical dehydration may be assumed to have lost 5 to 7 per cent of his body weight, and the amount of water administered intravenously in the first twenty-four hours should be about 7 per cent of his body weight. Half of this infusion should be given in the two or three hours before surgery, the rest at a rate not exceeding 400 cc. an hour and preferably spread over the full twenty-four hours, to minimize the danger of pulmonary edema. Hypochloremia can be corrected according to Coller's rule 3-namely, that the number of grams of sodium chloride to be administered to restore the normal plasma chloride level is : 560 -
Plasma chloride (as mg. per lOOcc. NaCl) X B d ,. ht (k ) 200. 0 Y V\elg g.
A somewhat smaller amount is usually sufficient. Until the plasma chloride level has been reported, hydration can be nicely initiated by starting intravenous infusion of a mixture of equal parts of 5 per cent dextrose in distilled water and 0.9 per cent sodium chloride solution. In most instances hydration and chlorination can be completed with this mixture. It is noteworthy that obstructing lesions of the right colon usually produce marked small bowel distention. It is of paramount importance that cases of apparent ileac obstruction be carefully scrutinized to determine whether there is cecal distention, for right colic cases fall even ahead of left colic and strangulating ileac lesions as the most acute and treacherous emergencies in the bowel obstruction field. Depletion of serum protein level is a serious problem, and restoration of advanced cases to 6 gm. per 100 cc. by transfusions of blood or plasma before emergency surgery is not likely to be possible. It should, nevertheless, be attempted. It is only in those small bowel cases not presenting signs of strangulation that depletion below 6 gm. per 100 cc. should dictate a day or two of delay for replenishment by transfusion. In all other cases of acute complete obstruction of ileum or colon, the risks of delay are greater than those of immediate surgery with vigorous use of plasma or blood before, during and after operation. SURGICAL TECHNICS
No attempt will be made here to cover completely the procedures which may be employed. Rather, certain of them will be presented which have proved themselves of particular value in the past few years. For incarcerated or strangulating hernia repairs in poorly prepared patients, more satisfactory and safe anesthesia may be obtained by novo-
ACUTE INTESTINAL OBS'l'RUCTION
1403
cain block than by either spinal or general methods. In other instances the policy at the University Hospitals has been to use cyclopropane and oxygen administered through a tracheal tube by a closed system machine; supplementation with curare by the intravenous route has simplified matters immensely. Most important, a good anesthetist in attendance widens the range of surgical possibilities, Placement of a No. 17 or No. 15 needle for intravenous infusion into the cubital vein at the elbow offers a large degree of security, especially if cross matched blood is present in the operating room. Aside from hernioplasties, most emergency operations for intestinal obstruction are exploratory in that the site of the block in the abdomen is unknown. Longitudinal or oblique incisions are, therefore, to be preferred in ileac obstruction, as they provide wider possibilities of extension and exploration. The right midrectus is very satisfactory. Closure of the abdominal wall is most safely made with interrupted fine silk sutures of 3 or 4 pound tensile strength. Most of these patients may then safely be ambulatory the day after surgery, a measure which seems to have simplified the postoperative course immensely. In transverse colostomy a transverse incision is essential to regular success. Wangensteen nasal suction tubes are placed in the stomach prior to surgery unless the case has been treated conservatively long enough already to have a Wild tube down.17 Suction is maintained throughout the sojourn in the operating room and postoperatively until sounds are normal and gas is passed by rectum, in the ileac obstructions, or by colostomy in the colic obstructions. This usually occurs two to three days after surgery. Nutrition by the intravenous route is continued in these cases until oral feedings are possible. Aseptic Decompression.-Wangensteen has described a method of aseptic decompressive enterotomy15 for dealing with marked ileac distention which permits safe exploration where indicated regardless of that distention. The author has used the method with slight modifications in some two dozen cases, with entire satisfaction as to relief of distention without peritoneal contamination. 4 In many cases it would have been utterly impossible to deal successfully with the obstructive mechanism if preliminary decompression of the fragile, thin walled bowel had not first been accomplished. Use of Wangensteen's aseptic suction enterotomy as modified in this series of cases may be performed with the set supplied by V. Mueller and Company or with equipment to be found in any well supplied operating room (Fig. 516). The essentials consist of an ordinary empyema trocar, a soft rubber catheter large enough just to pass through the trocar, a long piece of Penrose drain, connecting tubing, a Wangensteen suction set, and sterile glycerin. Secure ridges for provision of anchorage of the bowel to the trocar may be formed by sliding three 2 or 3 mm. segments of heavy snug-fitting rubber tubing onto the end of the trocar before autoclaving. The heat of sterilizing seals them securely. As indicated in Figure 516, a piece of Penrose drain is tied on the sidearm of the trocar and
1404
CLARENCE DENNIS
Fig. 516.-Modified Wangensteen aseptic decompressive suction enterotomy. A, Method of emptying a distended segment of small bowel preparatory to enterotomy. The segment so emptied between the fingers should be 25-30 cm. long. Application of the rubber-shod Scudder clamps should be as light as possible as more trouble with adhesions arise from this site than from suture lines. B, Placement of a double purse string to secure the bowel to the trocar. Atraumatic ()() catgut is used. After placement of the purse strin~s, a 1 cm. incision in
ACUTE INTESTINAL OBSTRUCTION
1405
covers the entire external length of the catheter, being tied securely over a glass connector in the back end of the catheter. A half ounce of glycerin inside the soft rubber drain serves as lubricant. A second piece of Penrose drain is tied around the handle of the plunger of the trocar to avoid leakage from that source. A long segment of tubing connects the catheter to a Wangensteen suction set. About twelve holes, each 3 mm. in diameter, are cut in the last 6 cm. of the catheter. In using the apparatus, the most distended free segment is delivered cautiously and milked empty between the second and third fingers of the two hands of the surgeon, and Scudder clamps are very gently applied to keep that segment empty. This maneuver allows contraction of the muscle layers and consequent thickening of the bowel wall so that a firm bite may be obtained for sutures without the danger of leakage through the paper thin walls present before emptying. A purse string of No. 00 catgut on an atraumatic needle is laid, the purse string being 15 to 20 mm. in diameter. A second purse string laid 3 mm. wide of the first is extremely effective in eliminating leakage later. A transverse incision 1 cm. long down to the mucosa is made in the center of the purse strings, and the end of the trocar is secured to the bowel by tight tying of the catgut strands. Greater security is afforded by tying each end over the sidearm of the trocar. Suction is first applied, and then the plunger of the trocar is used to perforate the mucosa and then drawn back. The catheter can now be inserted into the bowel, and the Scudder clamps removed. the center exposes the intact mucosa so that easy perforation will be possible with the plunger point. e, Securing of trocar. As an added precaution against leakage, the ends of the double purse string are tied over the side arm of the trocar. Following perforation of the mucosa, the plunger is withdrawn and the catheter is slipped into the bowel. Soiling is prevented by protection of both the plunger shaft and the catheter by soft rubber drains, lubricated with glycerin. D, Suction decompression. Very gentle lifting of the segments of bowel will direct content to the catheter. The entire small bowel can be emptied by this means, particularly if a 3 foot catheter is employed. E, Clean removal of the trocar. A transverse row of interrupted Lembert sutures is preplaced and held up with hemostats in such manner as to support the bowel. The catheter is withdrawn into the trocar, but suction is maintained. A No. 11 Bard-Parker blade cuts the two purse strings, and the trocar and attachements are placed cleanly into a large basin placed for the purpose immediately beside the bowel. F, Closure of the defect. Traction on the ends of the preplaced Lembert sutures apposes the serosa without soiling. G, Completion of closure. Closure may be reinforced by a second row of silkHalsted mattress sutures, and 30 mg. of sulfanilamide powder may be implanted between the rows. Recently the second layer of sutures and the sulfonamide have been discarded as unnecessary. The closure process may be eliminated altogether in strangulation if a segment is employed close enought to the necrotic bowel to permit block excision of the entire area-with immediate anastomosis. (Modified from Wangensteen's Intestinal Obstructions by permission of the author and Charles C Thomas, publisher. Reprinted by permission of W. H. Cole and Appleton Century Co. from Cole's "Operative Technique," 1949.)
1406
CLARENCE DENNIS
It is now practicable to empty the entire small bowel above the site of obstruction by very gentle threading of the catheter through the bowel in both directions and by gentle elevation of the fluid filled loops to lead fluid to the catheter. Direction of attention to the obstructing mechanism is in order only after rather complete ileac evacuation. The danger of accidental tearing of the bowel wall is then minimized, and spillage in event of accident is absent or minimal. In some instances it will be found that strangulation has rendered a segment nonviable. In such cases it simplifies the procedure to have placed the trocar close to this area, enabling the surgeon to resect both the gangrenous bowel and the trocar site in one segment. This is usually accomplished by selection of the most distended loop, usually the lowest one, for decompression. If simple obstruction is found and relieved without resection, closure of the decompression site must be accomplished. To do this cleanly, an effective procedure is to preplace six to eight Lembert stitches in a transverse row in such fashion that tying after removal of the trocar will invert all the bowel involved in the purse strings and 0.5 cm. more on each side. After preplacement of the sutures, the catheter is withdrawn into the trocar, and the suction left in force. By traction on the catgut ties previously brought over the sidearm, each purse string can be visualized and divided with a No. 11 Bard-Parker knife blade. A discard basin held immediately adjacent to the bowel receives the trocar, and other instruments, with minimal chance for contamination. The Lembert sutures are tied, completing the closure. A second row of closure has been abandoned as unnecessary. The rather extensive inversion of tissue which occurs does not occlude the lumen because of the marked stretching of the bowel produced by preoperative distention. In no instance has clinical obstruction in the postoperative period been recognized. On a few occasions laparotomy for other lesions at a later time has made possible reexamination of this area. Except for the presence of suture, it is usually very difficult to differentiate this segment from others in the small intestine. Resection of Gangrenous Bowe1.-Experience at the University Hospitals has shown that resection with primary end-to-end anastomosis is a practicable and safe method of dealing with small bowel obstruction in which nonviable intestine is found. 6 The anastomosis recommended is a modification of that of Martzloff and Burget. One of the chief difficulties which this procedure is designed to overcome is the end-to-end union of segments of widely differing diameter without the formation of blind pockets or kinks. The mesentery is meticulously cleaned from the distended bowel proximal to the point of obstruction, a site close to the point of approach of large vessels in that mesentery being chosen (Fig. 517, 1). A slender, crushing, anastomosis clamp is placed across the bowel, from the antimesenteric border, at an angle of about 75 degrees from the long axis of
ACUTE INTESTINAL OBSTRUCTION
1407
the gut. The clamp crosses the mesenteric border about 6 mm. below the edge of the unremoved mesentery. In order to minimize the danger of spillage of any of the content of the distended bowel during the later stages of the procedure, the contents are cautiously milked back between the fingers for 10 or 20 cm. from the
Fig. 517.-1, Placement of the first anastomosis clamp on the distended bowel above the point of obstruction. The clamp crosses the bowel at an angle of 75 degrees and at the mesenteric border about 6 mm. fr.om the edge of the unremoved mesentery. The bowel has been milked back and a rubber shod clamp is applied to prevent spillage. 2, Placement of the second anastomosis clamp on the contracted bowel below the point of obstruction. The line of crush begins 6 mm. from the unremovedmesentery, crosses obliquetly two-thirds of the bowel and passes for a distnce parallel with the antimesenteric border before crossing the remaining one-third of the bowel. a, This length of crushed tissue, equal to that in 1, is obtained by distorting the bowel with Allis forceps. This clamp is placed from the mesenteric border. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
clamp, and a rubber shod intestinal clamp is lightly applied. This clamp remains in place until the completion of the anastomosis. Below the point of obstruction, the diameter of the bowel is usually one-third to one-half that above, and the anastomosis clamp must therefore be placed much more obliquely to attain a length of crushed tissue equal to that above. Most satisfactory ..tomas have been achieved by the application of the clamp from the mesenteric border with distortion of the bowel by Allis forceps lightly applied in such fashion that the line of
1408
CLARENCE DENNIS
crush, beginning at the mesenteric border, crosses obliquely two-thirds of the way to the antimesenteric border, then runs longitudinally down the bowel to gain the necessary length of crush before it crosses the remainder of the gut (Fig. 517,2, 2a). The cleaning of the mesentery and the placement of the clamp with regard to the cleaned area are accomplished as on the distended intestine. *
Fig. 518 -3, Cutting the bowel between the clamps described in Figure 517 with the cautery. To prevent spillage additional clamps are placed between those applied for anastomosis and the specimen to be removed. 4, Placement of the posterior running fine catgut suture. The clamps are held side by side, so that the bowel ends are brought together with 180 degrees' rotation of one with respect to the other. The suture is laid with the clamps rolled away from each other as shown. The bites are 5 mm. long and the gaps between bites are 4 mm. a, Placement of each end bite parallel with the long axis of the gut assures good inversion later. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
A similar clamp is placed between the bowel to be resected and each of the clamps already described, a 3 or 4 mm. gap us~ally being left be-
* The value of this type of placement is not limited to anastomoses performed in the presence of obstruction. In the terminal ileum under normal conditions the lumen is small enough to render anastomosis without undue reduction of the lumen difficult. This type of placement of clamps with 180 degrees' rotation has proved uniformly successful under these circumstances. In other sites where bowel ends of unequal diameter are to be joined, such a's in end-to-end ileocolostomy after right hemicolectomy, this type of anastomosis has also proved uniformly successful.
ACUTE INTESTINAL OBSTRUCTION
1409
tween clamps. The intestine is cut in the gap between each of these pairs of clamps with the actual cautery (Fig. 518, 3). The anstomosis clamps are laid side by side, thus bringing the bowel ends together with one end rotated 180 degrees with respect to the other about the long axis of the gut (Fig. 518,4). Ideally the length of the area of crush in the two clamps is identical, for by this precaution the most accurate apposition of the two ends can be attained in making the anastomosis. The clamps are rotated away from each other, and a running bast-
Fig. 519.-5, Placement of the anterior running catgut suture. The clamps have been rolled together. 6, Removal of clamps. Tension is applied to the two ends of each of the running sutures, the clamps are carefully loosened until the tips are spread 1 or 2 mm. and the clamps are cautiously and simultaneously removed. ~From Surgery, Gynecology and Obstetrics, Vol. 77.)
ing stitch of No. 00 or No. 000 plain catgut on an atraumatic needle is placed posteriorly, about 5 mm. being taken in each bite, with a slightly smaller gap (4 mm.) being left between bites. Subsequent inversion occurs spontaneously at the time of withdrawal of the clamps only if the ends of the running sutures are properly placed; inversion of the corners with instruments, which invites contamination, may thus be avoided. Each end bite of each suture must be about 5 or 6 mm. long and parallel with the axis of the bowel, and should emerge close to the clamp (Fig. 518,4a).
The anastomosis clamps are now rolled together, and a similar running stitch is placed anteriorly (Fig. 519, 5).
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CLARENCE DENNIS
Tension is applied to the two ends of each of the basting sutures, the clamps are carefully loosened until the tips are spread 1 or 2 mIll., and the clamps are cautiously and simultaneously withdrawn (Fig. 519, 6). If the sutures have been properly placed, inversion of the cut ends of intestine will occur with no further manipulation, and clean serosal approximation will result. Tension is maintained on the basting stitches while the ends of the posterior strand are tied to the corresponding ends of the anterior strand.
Fig. 520.-8, Tying of the Halsted mattress sutures, with maintenance of tension on catgut strands. The posterior side is treated in similar fashion. 9, Rear view of anastomosis, showing placement of stitch to close the mesenteric defect. (From Surgery Gynecology and Obstetrics, Vol. 77.)
With maintenance of tension on the ends of the basting stitches throughout, interrupted Halsted mattress sutures of 2.5 pound test silk or cotton are laid anteriorly, and the mattress sutures are tied just tightly enough for snug apposition (Fig. 520,8). The bowel is rolled over, and the posterior closure is similarly reinforced, tension being continued to this point on the ends of the catgut strands. Tension on the basting sutures is gradually lessened as the stoma is broken down by inverting the bowel below the anastomosis with a thumb or two fingers and thus pushing through the stoma. The catgut basting stitch, which is circular by virtue of the knots at the ends of the suture line, is held taut by this device while inversion Halsted mattress sutures are placed at the ends. The
ACUTE INTESTINAL OBSTRUCTION
1411
catgut ends are cut just inside the knots on one end and withdrawn altogether. They have served to hold the bowel for placement of the silk sutures, and the removal of them leaves a one layer silk anastomosis, thus free of the delay in mucosal healing resulting from continued presence of the catgut. To close the mesenteric defect, a stitch near the center of the posterior suture line is threaded on a needle and a small bite of each mesenteric edge is taken 3 cm. from the bowel (Fig. 520, 9), and behind it, and thus the defect in the mesentery is tied. From this point to the root of the
4~m.},
A"::W 3mm.
eM.
Fig. 521.-The anastomosis clamp 9. (From Surgery, Gynecology and Obstetrics, Vol. 77.)
mesentery, interrupted silk sutures are placed. Efforts to cover the suture line with omentum have been abandoned as useless. The clamps used in maki:ng this anstomosis differ from those of Martzloff and Burget in that they are shorter. and lighter. * With the shorter clamp one may rely less on the springiness of the instrument to crush the tissue at the tip, and the clamps may therefore be more easily removed during the anastom~sis. Deep, sharp, longitudinal, matching grooves are cut on the jaws of the clamp (Fig. 521). The advantages of this type of anastomosis over many of those described in the literature are as follows: 1. End-to-end anastomosis avoids the formation of the blind pouches
* Clamps can be obtained from V.
Mueller Company, Chicago.
1412
CLARENCE DENNIS
which result from closure of both ends and side-to-side anastomosis (Fig. 522). 2. End-to-end anastomosis necessitates but one suture line, whereas closure of the ends and side-to-side anastomosis requires three lines. 3. Aseptic procedure permits apposition of serosal surfaces uncontaminated with luminal contents, a point heavily supported by experimental work. 4. Obliquity of placement of clamps permits the best possible blood supply to the line of suture, for the vessels follow a circular course around the bowel and are not, therefore, interfered with before reaching the suture line.
a'
b'
Fig. 522.-a, Schematic drawing to illustrate the angulation resulting from endto-end anastomosis for bowel cut at 45 degrees and apposed without rotation. b, The obviation of angulation accomplished by rotation of one segment with respect to the other is apparent. (Reprinted from Surgery, Vol. 5.)
5. Rotation of one segment of bowel with respect to the other minimizes angulation and therefore minimizes possibility of obstruction at the point of anastomosis, as shown in Figure 522. 6. Rotation of the bowel avoids the dangers of closure without peritoneum at the mesenteric border; in other words, by this rotation peritoneum is provided on one surface or the other completely around the line of inversion. * 7. This type of anastomosis avoids the danger of stenosis at any time in the postoperative period. There has been no case of dysfunction secondary to the quarter twist imposed on each end to be anastomosed. Use of this or the Martzloff-Burget anastomosis should not be
* In over sixty clinical cases and sixty experimental anastomoses, no instance of leakage at the ends of .the suture line, i.e., at the mesenteric border on one side, has occurred. In one case leakage has occurred in the midportion, but here the peritoneum was found contaminated with feces when the abdomen was first opened.
ACUTE INTESTINAL OBSTRUCTION
1413
Fig. 523.-Closed, one-layer, interrupted silk anastomosis. a, Placement of first Halsted mattress sutures. Note that the clamps are placed not quite completely across the bowel. The point of exit of sutures closest to the modified Martzloff clamp is 7 mm. from the cut edge of the bowel. If the bowel is less than 2 em. in diameter, either smaller clamps may be used, or the sutures may be placed immediately adjacent to the clamps and the clamps removed before tying the stitches, or, preferably, the two layer, oblique, end-to-end anastomosis may be used, best with withdrawal of the inner catgut basting stitch after completion of the silk suture line. When the distance from the cut edge of the bowel to the . stitches is more than one-third the length of tissue along the crushing clamps, real danger of obstruction is present. b, Completion of back side of anastomosis, tying also over ends of clamps. c, and d, Front side of anastomosis. e, Removal of clamps-delayed until all but two sutures have been tied. j, Completion of anastomosis by tying last two sutures after removal of clamps. The total number of sutures for intestinal anastomosis has varied from 11 to 18. (From Annals of Surgery, Vol. 126.)
attempted by those unfamiliar with intestinal suture until some experience has been gained in the dog. Difficulties may arise from improper placement of the catgut suture, tearing of the friable distended bowel by
1414
CLARENCE DENNIS
use of heavy instruments or too heavy sutures, and postoperative adhesion formation at the site of placement of the Scudder clamps. There is no need to resect bowel because it is distended or because it fails to contract on stimulation by snapping with the finger, or because it does not offer normal resistance to placing the needle. The greatest gentleness will be rewarded by absence of postoperative cramps or obstruction. In infants in whom intussusceptions prove irreducible or frankly gangrenous, resection is essential. Gross and Ware have reported a method in which a temporary double barreled ileostomy or ileocolostomy is closed after three to four days.12 His is an enviable record, and the first to be presented with low mortality. To the author it has seemed more. direct and neater to do a primary closed anastomosis. Here both the upper and lower segments are large in diameter, and the anastomosis may be done over narrow anastomosis clamps without the temporary use of catgut (Fig. 523). Much discussion centers about the choice of closed as against open anastomosis. Where good preparation of the bowel is possible, it does not make much difference which is used. In obstruction cases this is not true, and comparison of open as against closed anastomosis series, both in the laboratory and clinically, shows that the results have been distinctly better where serosal contamination has been minimized by closed anastomosis. 9 Femoral Hernia with Gangrenous Bowel.ll-Under local block anesthesia, a vertical incision is made over the bulge in the groin and carried cautiously down to the peritoneal sac. The contents of the sac can be visualized through the remaining wall; bloody fluid, pus, feces, or black bowel can usually be readily recognized (Fig. 524, a). In case any of these indicates the presence of gangrenous bowel, dissection in this area is discontinued, and an incision is made 2 cm. above the inguinal ligament and parallel to it, and the vertical incision is continued upward to it to make a T-shaped incision (Fig. 524, b). The aponeurosis of the external oblique muscle is split parallel to the ligament and about 1 cm. above it, and extended into the external inguinal ring. The margins of the internal oblique and transversus muscles (and the cord if the patient is male) are elevated, the deep epigastric vessels are divided and ligated, and the peritoneum is incised parallel with the oblique skin incision. From this vantage point, the viscera entering the hernia may be easily seen. Omentum, if involved, is easily divided and ligated close to the neck. The small bowel entering the sac is prepared by division of the mesenteric attachment from the proximal to the distal side of the incarcerated loop of bowel. Two Ochsner clamps are placed across each of these limbs of bowel, and the ileum is severed between each pair with the cautery. After the gangrenous sac contents have been freed from intra-abdominal attachments, the inguinal ligament is divided close to the pubic attachment and split laterally, leaving enough heavy aponeurotic tissue
ACUTE INTESTINAL OBSTRUCTION
1415
applied to the front of the neck of the sac to prevent relaxation of the neck and release of the soiled content. The sac is encased in a rather firm layer of fascia derived from the femoral canal. Dissection outside it frees the entire sac except for the residual fibrous portions of the ring, which can then be cut under direct vision from the surrounding tissues and left on the neck of the sac (Fig. 525). Palpation for an anomalous obturator artery adds an item of safety here. The entire contaminated area may then be removed intact, without soiling of the remaining field. Further preparation of the remaining bowel ends may then be done easily, and oblique, aseptic end-to-end anastomosis is performed as for
Fig. 524.-Femoral hernia with gangrenous bowel. Skin incision: a, for recognition of gangrene, without opening sac; b, completion of incision after recognition of gangrene. (From Surgery, Vol. 22.)
any case of resection in the presence of obstruction. Following closure of the mesentery, the bowel is dropped back into the abdomen. Performance of the anastomosis is facilitated by placement of the posterior silk row as interrupted Cushing stitches before use of the running catgut. Closure of the peritoneal defect in the repair of the hernia is easily accomplished because of the usual mobility of the peritoneum in this area. Closure is usually made by interrupted mattress sutures of 2 pound test silk, approximating the margins of the defect resulting from excision of the sac in a vertical line and closing the original oblique peritoneal incision in a line parallel with the original opening. Repair of the hernial and surgical defect is simplified by application of the prinpiples of the McVay-Harkins modification of the Lotheisen hernioplasty. The margins of the internal oblique and transverse muscles are sutured to Cooper's ligament as far laterally as the femoral vein and
1416
CLARENCE DENNIS
to the inguinal ligament lateral to that point (the cord in the male ordinarily being left external to this layer). A McVay-Harkins relaxing incision may be made in the posterior layer of the anterior rectus sheath if needed to gain approximation without tension. The inguinal ligament is restored easily by interrupted sutures of 3 pound test silk, approximating it as far medially as it will go without undue tension, to the lacunar ligament and to Cooper's ligament.
Fig. 525.-Femoral hernia with gangrenous bowel. Separation of neck of sac with retention of intact fibrous ring. (From Surgery, Vol. 22.)
The aponeurosis of the external oblique muscle is finally approximated with interrupted silk (over the cord in the male), completing the hernial repair proper. Silk closure of the skin is used without drainage. If no evidence of necrosis is apparent upon first exposure of the sac, it is well to dissect the sac rather widely and to place moist packs about it before incision of the sac wall. In case no nonviable bowel is encountered, the sac, of course, may be widely opened, the hernia reduced by enlarging the neck medially, and the repair done entirely from below.
ACUTE INTESTINAL OBSTRUCTION
1417
Transverse Colostomy.-Although the possibility of primary surgery upon obstructing colic lesions appeals to the imagination, experience has shown that the risk is more than twice as great as that of preliminary decompression followed by resection after recovery from distention. These results are considered due to edema and poor circulation in the thinned and stretched bowel wall, combined with actual bacterial invasion from the lumen. Only after these changes have been corrected by recovery after decompression, has surgery to the lesion itself proved feasible. Decompression of the distended colon seen in acute obstruction is to be regarded as a surgical emergency. Among most surgeons, cecostomy has long been considered the procedure of choice for decompression of the distended colon. Because of the impossibility of really aseptic decompression by cecostomy and the difficulty of complete delivery of the cecum in the presence of marked distention, the mortality is high in that procedure; Wangensteen states that the mortality associated with this operation at the University of Minnesota Hospitals was nearly 50 per cent, a figure corroborated by CampbelP and others. Several years ago, Wangensteen suggested that decompression in acute left colic obstruction be accomplished by transverse colostomy.l6 He emphasized that the incision could be precisely placed over the distended transverse colon to be exteriorized if a preliminary scout film with a coin on the umbilicus was made (Fig. 526). This is a sound precautionary measure. Wangensteen particularly emphasizes in his teaching at the clinic here that this procedure must be done through a transverse incision, preferably cutting across the right rectus muscle halfway between the umbilicus and the xyphoid. Patients have been referred to this hospital after attempts to accomplish decompression of the transverse colon through vertical abdominal incisions, and this procedure has failed because of inability to deliver the distended transverse colon through such an incision. Decompression of the bowel intraperitoneally in order to facilitate delivery through a vertical incision invites the hazards of cecostomy. Such decompression prior to delivery is almost never necessary after entry through a properly placed transverse incision. In performing transverse colostomy, the colon is elevated over one or two glass rods and further fixed by fine silk sutures securing the omentum and fatty tags to the peritoneum and rectus sheath (Wangensteen). In the presence of distention, no sutures are placed in the bowel wall proper. Massive petrolatum dressings are placed to cover all the field but a small area of the bowel before insertion of a hypodermic needle for decompression. If the bowel refills quickly, it is aspirated every few hours during the next two days; at that time a 6 cm. longitudinal anterior cut is made with the cautel'Y. The glass rods are removed at ten days. This procedure accomplishes complete deviation of the fecal stream, a matter of some i.mportance in subsequent surgical procedures. Primary Resection of Right Colic Obstructing Cancers.-In obstructing cancers of the right colon, the problem is simplified because the asep-
1418
CLARENCE DENNIS
tic decompression maneuver may easily be applied at the terminal ileum, with decompression of the colon by passage of the catheter through the ileocecal valve, followed by immediate right hemicolectomy with primary closed ileotransverse colic anastomosis. Such a plan has been used five times without incident, with uniform recovery, and with early dismissal from the hospital. One would expect better long term results because of
Fig. 526.-Technic of decompressing the distended colon. Sketch of a radiogram from a case. A five-cent piece is taped over the umbilicus. In the insert, on the left, the actual size of the nickel drawn to scale is shown in a. The 33 per cent enlargement on the anterior abdominal wall is shown in b. The intestinal coils within the abdomen are enlarged 25 per cent. In the insert on the right, the method of deflating the colon on completion of the operation is shown. After a few such aspirations, the bowel is incised and a tube is inserted before it is finally cut for 6 em. longitudinally. The tension in the bowel is determined before its contents are aspirated. (From Wangensteen, O. H., Intestinal Obstructions, Ed. 2, Springfield, Ill., Charcles C Thomas, 1948.)
earlier removal of the offending carcinoma, but no data are available on this point. Reduction of Volvulus of the Sigmoid Colon.-Dr. Christian Bruusgaard of Ullevaal Hospital, Oslo, Norway, recently spent a year with us at Dr. Waagensteen's clinic. His report of proctoscopic deflation of the distended sigmoid involved in torsion l was supplemented by repeated demonstrations of the efficacy and safety of the method. In patients suffering volvulus of the sigmoid colon, in whom no evi-
ACUTE INTESTINAL OBSTRUCTION
1419
dences of impaired viability are present, insertion of a proctoscope until the spiraling folds of mucosa can be seen (at from 15 to 25 cm.) facilitates the passage of a soft rectal tube into the distended sigmoid loop. The brisk escape of gas and liquid heralds a successful result. As Bruusgaard and Wangensteen demonstrated, elective primary sigmoid resection some two weeks later safel¥ relieves the patient of the high risk of recurrence. In event of evidences of loss of viability, laparotomy with exteriorization of the sigmoid loop is essential and may be followed by later closure of the resultant double-barrelled colostomy. CONCLUSION
An absolutel¥ essential factor to the consistently successful management of bowel obstruction is accurate diagnosis. Patients with badly depleted nutritional status may have surgery for acute complete bowel obstruction deferred only if signs indicate the process to be a simple small bowel lesion. Right complete colic obstructions appear to present the most acute surgical emergency in the whole obstruction field, with left colic and strangulating small bowel lesions sharing second place. With the advent of the Wangensteen aseptic decompression technic the era of routine nonoperative management has passed, and the well trained surgeon is safest to explore all cases of bowel obstruction. The small bowel and right colic lesions are best explored through a vertical or oblique incision; in left colic obstructions a right upper transverse incision is recommended for transverse colostomy. More direct technics have reduced the risks in strangulating hernias, in marked distention, in right colic obstruction, in intussusception, and in volvulus of the sigmoid colon. Despite these technics, progress can be expected only by careful attention to water and salt balance as Coller and his group have stressed, and to the protein metabolism of these usually debilitated patients. REFERENCES 1. Bruusgaard, C.: Volvulus of the Sigmoid Colon and Its Treatment. Surgery 22: 466, 1947. 2. Campbell, O. J.: Surgery of Carcinoma of the Colon. Minnesota Med. 23: 215, 1940. 3. Coller, F. A. and Maddock, W. B.: Water and Electrolyte Balance. Surg., Gynec. & Obst. 70: 340, 1940. 4. Dennis, C.: Surgery of the Small Intestine. In Operative Technique, Warren Cole, Editor. Appleton-Century, 1949. In press. 5. Dennis, C.: Oblique, Aseptic, End-to-end Intestinal Anastomosis. Surgery 5: 548, 1939. 6. Dennis, C.: Oblique, Aseptic, End-to-end Ileac Anastomosis, Procedure of Choice in Strangulating Small Bowel Obstruction. Surg., Gynec. & Obst. 77: 225, 1943. 7. Dennis, C.: Treatment of Large Bowel Obstruction. Surgery 15: 713,1944.
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CLARENCE DENNIS
8. Dennis, C.: Resection and Primary Anastomosis in the Treatment of Gangrenous or Non-reducible Intussusceptions in Children. Ann. Surg. 126: 785,1947. 9. Dennis, C.: Some Considerations in Intestinal Anastomosis. Minnesota Med. 1949. In press. 10. Dennis, C. and Brown, Schuyler P.: Treatment of Small Bowel Obstruction; Procedure Used at the University of Minnesota Hospitals. Surgery 13: 94, 1943. 11. Dennis, C. and Varco, Richard L.: Femoral Hernia with Gangrenous Bowel Surgery 22: 312, 1947. 12. Gross, R. E. and Ware, P. F. Intussusception in Childhood; Experience in 610 Cases. New England J. Med. 239: 645,1948. 13. Martzhoff, K. H. and Burget, G. E.: Aseptic, End-to-end Anastomosis and a Method for Making Closed Intestinal Loops Suitable for Physiologic Studies. Arch. Surg. 23: 542,1931. 14. Wangensteen, O. H. Personal communications. 15. Wangensteen, O. H.: New Operative Techniques in the Management of Bowel Obstruction; Aseptic Decompressive Suction Enterotomy, Aseptic Enterotomy for Removal of Obstructing Gallstone, and Operative Correction of Non-rotation. Surg., Gynec. & Obst. 75: 675,1942. 16. Wangensteen, O. H.: Intestinal Obstructions. 2d Ed. Springfield, Ill., Charles C Thomas, 1948. 17. Wild, J. J.: The Design and Management of Long Intestinal Tubes. Surgery 25: 779, 1949.