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Elimination of upper abdominal distention by continuous aspiration during operation
ELIMINATION OF UPPER ABDOMINAL DISTENTION BY CONTINUOUS ASPIRATION DURING OPERATION GERALD H. PRATT, M.D., F.A.C.S. Instructor
in Surgery,
New York Post-Graduate NEW
T
Medical SchooI of CoIumbia University
YORK CITY
HE use of the principIe of suction the decompression maintained. The stomach couId be entireIy Aattened and the siphonage by inIying duodena1 tube air, gas, regurgitated biIe and saIiva evacuafter an abdomina1 operation has become quite genera1 and at many cIinics is ated as rapidIy as coIIected. It is advantageous even when the stomach has been a routine procedure. The work of WancarefuIIy prepared by gastric Iavage, as gensteen and others has been instrumenta the nervous excitation, the vomiting reffex, in standardizing the procedure. SeveraI and crying or swaIIowing of air wiI1 distend apparatus have been devised for the purpose, nearIy a11 based on the underIying the stomach. In our gastric work we preprincipIe of the suction created by the pare the stomach with a Iavage of diIuted hydrochIoric acid soIution, Ieaving some effort of a Auid in an inverted eIevated container to pass to a container at a Iower of this soIution in the stomach unti1 we IeveI. are prepared to open the organ. At that During operations on the upper abdotime we evacuate the Auid by opening the men, particuIarIy the stomach, duodenum suction-siphonage system. Gastric Iavage and gaI1 bIadder, surgeons have been on the operating tabIe can be easiIy efannoyed by the protrusion or “ffopping fected in this way. around ” of the distended stomach and WhiIe on the Babcock SurgicaI Service smaI1 intestine, caused frequentIy by the at the TempIe University, a standard apeffort of the patient to gag, vomit or strain. paratus was devised by the author for the We have shown that nearIy a11 of this purpose of decompression. This apparatus distention is swaIIowed air. This makes the has the added advantage of being a portoperation technicaIIy more diffrcuIt and abIe singIe unit, easiIy controIIed by the at times actuaIIy hazardous. It is parnurse, attendant or anesthetist. (Fig. I.) ticuIarIy troubIesome when anesthesia is This evacuator has been partiaIIy described incompIete or wearing off, as in IocaI or eIsewhere, but in brief utiIizes the prespina anesthetics, or with the vioIent viousIy mentioned principIe of hydrauIic breathing of a patient who takes the in- suction with the additiona feature that haIation anesthesia poorIy. At times, the the water jugs can be changed at wiI1 withorgans become so distended that vision is out disturbing the set or the patient. When impossibIe, and anesthesia must be carried one jug is empty it is Iowered and the to a dangerous point or the operation even other one rises whiIe a three-way valve terminated. controIs the center or coIIecting jug. A After considerabIe experience with sucburette for irrigation of the duodena1 tube tion siphonage in a11 its forms, it was de- by way of a “Y” tube is kept cIamped off cided to see if the suction wouId aid us in when not in use. overcoming this distressing operation probThe surgeon, who has spent time vaIuIem. The duodena1 tube was pIaced through abIe to the patient and nervous energy the nose and the suction kept open throughimportant to himseIf, in efforts to protect out the operation. We were surprised to his heId from the distended viscera with note the ease with which the distention traumatizing packing and retractors, wiI1 of the viscera couId be eIiminated and be surprised at the ease with which this _ 618
NEWSERXESVOL. XXXIV.
No.
3
Pratt-Upper
AbdominaI
di~cuIty can be surmounted. The small tube through the nose in no way interferes with the anesthetist if a genera1 anesthetic is used, and with the suction open regurgitation of the tube is nearIy impossible. At the end of the operation the tube may be Ieft in pIace and a secondary distention prevented by aspiration at indicated intervaIs. With distended gaI1 bIadders which we desire emptied before their remova1, without the contamination of the aspirating needfe, we have been abIe with the abdomen open to place the tip of a nasa1 duodena tube in the second portion of the duodenum, and with the suction appIied to cohapse the gaII bIadder by drainage through the common duct. Where the stone is impacted tightIy in the neck, it is sometimes possibIe to work it back manuaIIy into the gaI1 bIadder, and then drain the gaI1 bIadder contents into the duodenum with the suction, thus eIiminating a possibIe peritonitis from a Ieaking puncture hoIe. We are continuing our experiments aIong this Iine at the present time. It is the suggestion, therefore, that surgeons working in the upper abdomen anticipate this distention factor by inserting the iniying duodenal tube before operation and having a suction siphonage device at hand ready for use. It is our experience that this suggestion wiI1 be a weIcome addition to the routine preparation. SUMMARY
the distention I. An aid in eIiminating factor during an abdomina1 operation is described, using the author’s modification of the Wa~gensteen type of suction siphonage.
Distention
2. The described. 3. The
Pratt efficacy
American ~~~~~~~Of surgery
evacuator of the
is
619
briefIy
evacuation
in
FIG. I. The Pratt evacuator in use during an operative procedure.
4. The
value of the procedure in operations upon the biliary tract in the presence of a tightIy distended gaI1 bIadder is outhned. 5. The routine insertion of a duodenal tube prior to operation and the attachment of an evacuation apparatus for continuous decompression during surgica1 procedures on the upper abdomen is advocated, and a pIan for gastric Iavage just prior to the opening of the stomach by this same method is presented.
in Surgery,
New York Post-Graduate NEW
T
Medical SchooI of CoIumbia University
YORK CITY
HE use of the principIe of suction the decompression maintained. The stomach couId be entireIy Aattened and the siphonage by inIying duodena1 tube air, gas, regurgitated biIe and saIiva evacuafter an abdomina1 operation has become quite genera1 and at many cIinics is ated as rapidIy as coIIected. It is advantageous even when the stomach has been a routine procedure. The work of WancarefuIIy prepared by gastric Iavage, as gensteen and others has been instrumenta the nervous excitation, the vomiting reffex, in standardizing the procedure. SeveraI and crying or swaIIowing of air wiI1 distend apparatus have been devised for the purpose, nearIy a11 based on the underIying the stomach. In our gastric work we preprincipIe of the suction created by the pare the stomach with a Iavage of diIuted hydrochIoric acid soIution, Ieaving some effort of a Auid in an inverted eIevated container to pass to a container at a Iower of this soIution in the stomach unti1 we IeveI. are prepared to open the organ. At that During operations on the upper abdotime we evacuate the Auid by opening the men, particuIarIy the stomach, duodenum suction-siphonage system. Gastric Iavage and gaI1 bIadder, surgeons have been on the operating tabIe can be easiIy efannoyed by the protrusion or “ffopping fected in this way. around ” of the distended stomach and WhiIe on the Babcock SurgicaI Service smaI1 intestine, caused frequentIy by the at the TempIe University, a standard apeffort of the patient to gag, vomit or strain. paratus was devised by the author for the We have shown that nearIy a11 of this purpose of decompression. This apparatus distention is swaIIowed air. This makes the has the added advantage of being a portoperation technicaIIy more diffrcuIt and abIe singIe unit, easiIy controIIed by the at times actuaIIy hazardous. It is parnurse, attendant or anesthetist. (Fig. I.) ticuIarIy troubIesome when anesthesia is This evacuator has been partiaIIy described incompIete or wearing off, as in IocaI or eIsewhere, but in brief utiIizes the prespina anesthetics, or with the vioIent viousIy mentioned principIe of hydrauIic breathing of a patient who takes the in- suction with the additiona feature that haIation anesthesia poorIy. At times, the the water jugs can be changed at wiI1 withorgans become so distended that vision is out disturbing the set or the patient. When impossibIe, and anesthesia must be carried one jug is empty it is Iowered and the to a dangerous point or the operation even other one rises whiIe a three-way valve terminated. controIs the center or coIIecting jug. A After considerabIe experience with sucburette for irrigation of the duodena1 tube tion siphonage in a11 its forms, it was de- by way of a “Y” tube is kept cIamped off cided to see if the suction wouId aid us in when not in use. overcoming this distressing operation probThe surgeon, who has spent time vaIuIem. The duodena1 tube was pIaced through abIe to the patient and nervous energy the nose and the suction kept open throughimportant to himseIf, in efforts to protect out the operation. We were surprised to his heId from the distended viscera with note the ease with which the distention traumatizing packing and retractors, wiI1 of the viscera couId be eIiminated and be surprised at the ease with which this _ 618
NEWSERXESVOL. XXXIV.
No.
3
Pratt-Upper
AbdominaI
di~cuIty can be surmounted. The small tube through the nose in no way interferes with the anesthetist if a genera1 anesthetic is used, and with the suction open regurgitation of the tube is nearIy impossible. At the end of the operation the tube may be Ieft in pIace and a secondary distention prevented by aspiration at indicated intervaIs. With distended gaI1 bIadders which we desire emptied before their remova1, without the contamination of the aspirating needfe, we have been abIe with the abdomen open to place the tip of a nasa1 duodena tube in the second portion of the duodenum, and with the suction appIied to cohapse the gaII bIadder by drainage through the common duct. Where the stone is impacted tightIy in the neck, it is sometimes possibIe to work it back manuaIIy into the gaI1 bIadder, and then drain the gaI1 bIadder contents into the duodenum with the suction, thus eIiminating a possibIe peritonitis from a Ieaking puncture hoIe. We are continuing our experiments aIong this Iine at the present time. It is the suggestion, therefore, that surgeons working in the upper abdomen anticipate this distention factor by inserting the iniying duodenal tube before operation and having a suction siphonage device at hand ready for use. It is our experience that this suggestion wiI1 be a weIcome addition to the routine preparation. SUMMARY
the distention I. An aid in eIiminating factor during an abdomina1 operation is described, using the author’s modification of the Wa~gensteen type of suction siphonage.
Distention
2. The described. 3. The
Pratt efficacy
American ~~~~~~~Of surgery
evacuator of the
is
619
briefIy
evacuation
in
FIG. I. The Pratt evacuator in use during an operative procedure.
4. The
value of the procedure in operations upon the biliary tract in the presence of a tightIy distended gaI1 bIadder is outhned. 5. The routine insertion of a duodenal tube prior to operation and the attachment of an evacuation apparatus for continuous decompression during surgica1 procedures on the upper abdomen is advocated, and a pIan for gastric Iavage just prior to the opening of the stomach by this same method is presented.