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Evisceration—A post-operative complication
EVISCERATION-A Attending
Surgeon, City Hospital;
POST OPERATIVE kIDOR KROSS, M.D., P.A.C.S. Associate Attending NEW
A
YORK
COMPLICATION
Surgeon, Beth Israel and Montefiore
Hospitals
CITY
N investigation was made of the post- for peIvic operations, showed rupture of the operative eviscerations that oc- wound in eIeven instances where fibroids curred in the surgica1 and gynecowere removed and in no instance where the IogicaI services of the Beth IsraeI HospitaI more frequent adnexal operation was from 1930 to 1936. By evisceration is performed, This may be due to the debiIity meant, in this report, not onIy wound rup- and asthenia brought on by the bIeeding ture, but aIso an accompanying protrusion which is so common a factor in fibroids. of omentum or intestine. During this period TABLE I No. of Cases 4,433 abdomina1 operations (not incIuding Age 2 20-29 inguina1 or femora1 hernias, or suprapubic 7 30-39 prostatectomies) were performed, and evis40-49 ‘5 12 ceration occurred in forty-four of these 50-59 60-69 4 cases. The frequency of occurrence was 70 and over 3 just a fraction more than I per cent. Sex TABLE II apparentIy pIayed no rBIe as an etioIogic Day of Rupture No. of Cases I factor, since twenty-four of these occurred 3 4 in the femaIe patients, and twenty in the ; 5 maIe. Since the gynecoIogica1 patients were 6 9 incIuded in this series, the sIight pres’ 8’ ponderance among the femaIes is thus 4 9 readiIy accounted for. 10 3 I II Numerous investigations have been made I2 1 and reports on the frequency of this compIication have been pubIished, but there is Before discussing the various theories of stiI1 Iacking a satisfactory expIanation for the etioIogy of evisceration, it wouId be its causation and deveIopment. The theoheIpfu1 to review briefly the manner of ries generaIIy advanced are: (I) faiIure of wound heaIing. This wiI1 heIp to expIain the suture materia1; (2) unusua1 strains; the frequency with which this accident (3) constitutiona factors, i.e., asthenia and occurs between the fourth and the eighth debiIity causing a faiIure of the heaIing post-operative days. Wound heaIing was studied in detai1 by MeIeney and Howes.‘f2 process; and (4) wound infection. In this series, the age of the patient did These investigators divide the process into not seem to pIay any rGIe, as the major part two stages, the first or exudative stage of the hospita1 popuIation was between the Iasting four or five days, and the second or third and fifth decades. The character of reparative stage beginning at the end of the incision itseIf has no important part the first stage and continuing unti1 the in this condition, and it is we11known that wound is fuIIy heaIed. There is no sharp, the frequency of wound rupture is about sudden demarcation between the two the same in most cIinics, in spite of the processes; the second stage begins before fact that the character of the incision in the first is fuIIy compIeted. In the first these different cIinics varies considerabIy. period an exudate develops. The character It is aIso interesting to note that the and extent of this phenomenon depends median suprapubic incision which is used upon severa factors: the number of dead 610
NEW SERIES VOL. XXXIX,
No.
3
Kross-Evisceration
and injured ceIIs, the amount of extravasated bIood and Iymph, the presence of dust and bacteria in the wound, and the amount of suture materia1 empIoyed. During this period, the tensiIe strength of the sutures diminishes rapidIy and the hoIding power of the tissues becomes Iess. During the second period, the strength of the wound increases rapidIy as a resuIt of the deveIopment of fibropIasia with uItimate scar formation. At this time the exudate undergoes absorption. The duration of the first period depends upon the character and extent of the exudate. Tissue necrosis and inflammation not onIy increase the duration of this period, but also deIay the beginning of the reparative or second stage, thus causing tissue strength to be gained more sIowIy. Since a11sutures act as foreign bodies, the quantity of suture materia1 and its buIk are important factors in the heaIing process. The tightness with which the tissues are coapted, and the tightness with which sutures and Iigatures are tied, have a direct bearing on the amount of tissue necrosis that takes pIace. This factor, which is so frequentIy overIooked, pIays a considerabIe rBIe in wound heaIing. In a series of experiments on stomach wounds in rats, Howes2 showed definiteIy that a11wounds, after the first day, steadiIy Iost strength up to the fourth day. From then on the wounds began to increase in strength, and after about the seventh day the tensiIe strength of the wound was such that when force was appIied by distending the stomach, rupture occurred in the tissues around the wound and not in the wound itseIf. Up to this time, the same force caused rupture to take pIace at the site of the wound proper. Howes aIso showed that with the use of siIk sutures, the first stage was of shorter duration than with catgut, and aIso that the reparative stage began earIier, proceeded more rapidIy and reached its greatest strength sooner. He aIso demonstrated that the exudate Iasted Ionger and that the deveIopment of the coIIagen fibers began Iater in the wounds where catgut was empIoyed.
American Journal of Surgery
611
As evidence in favor of the theory of failure of the suture materia1 itseIf, numerous exampIes have been pubIished in which at secondary operation no trace of the suture materia1 couId be found. There is no doubt thit this expIanation may account for some cases where there is a combination of severa factors, such as premature absorption of catgut or tearing of catgut, in the first few days after operation before tissue heaIing has advanced perceptibIy, accompanied by sudden increase in intraabdomina1 pressure, especiaIIy in the presence of infection. Inspection of TabIe II, however, shows that many cases occur when tissue heaIing is quite advanced, where there is no evidence of premature absorption of catgut, and where there is no evidence of infection. In one case, evisceration occurred aIthough the suture materia1 consisted of unabsorbabIe siIkworm gut. CoIp,3 who reported the resuIts of a thorough investigation of these cases at the Mount Sinai HospitaI, hoIds that the primary disease is. undoubtedIy the most important factor in the production of evisceration. It is aIs interesting to note that SokoIow,4 who aIso hoIds this view, caIIed attention to the frequency with which wound rupture occurred among the northern peopIe, especiaIIy in the earIy part of the year. This he ascribed to the Iack of vitamin C and to the genera1 fatigue at the end of the very Iong winters in northern countries. From the nature of the diseases for which operation was instituted, it seems to be apparant that debiIitating conditions constitute a frequent and common association with wound rupture. (TabIe III.) In addition to the genera1 asthenia and its interference with norma wound heaIing, Grace’ considers sudden increase in intraabdomina1 pressure to be the direct and most frequent cause of wound rupture. That there is this reIationship can be seen both from the tabIes he shows in his pubIication and aIso from the post-operative factors tending to sudden increase in the intra-abdomina1 pressure, as shown
612
Kross-Evisceration
American Journalof Surgery
in the study IV.) It is not report that immediateIy sneezing.
of this series of cases. (TabIe uncommon for the patient to he feIt something give way after a speI1 of coughing or TABLE III
Nature of Disease Carcinoma Stomach........................ Colon.......................... Pancreas........................ Liver.. .. Rectum......................... Gall-bladder.. Uterine fibroids.. Biliary system.. . Peptic ulcer.. . . Acute appendicitis. IntestinaI adhesions.. Intestinal obstruction., Tuberculosis of cecum.. Hydatid mole.
No. 5 4
1 I I I II
.‘. .
8 5
.
z .
.
2
.. . ..
I I
.
I
TABLE IV
Post-operative CompIications Vomiting. . . . . Restlessness.. . . Distention. . . Cough. . . .. Belching. . .
No.
. 26 20
.
Ig
.
Nausea...........................
Retching..
.
16
. . .
I2 II 7
In view of the usua1 suddenness and unexpectedness of the evisceration, it is worth whiIe emphasizing a cIinica1 observation which in many instances gave warning of an impending and as yet unrecognized evisceration. This was the presence of a dressing saturated with bIoody serum. This occurred in twenty-four cases of the present series. (TabIe v.) TABLE v Day of Appearance No. of Cases Post-Operative 2 4 2 : 7 s’ IO II
5 5 2 I
In considering the theory that genera1 constitutiona factors are responsibIe for this condition, two questions immediateIy come to the fore. How can one expIain the fact that the rupture so frequentIy occurs in one part of the wound onIy, when the rest of the incision has heaIed
MARCH,1938
firmIy and fuIIy? Again, how, on the basis of this theory, can one expIain the firm heaIing of the same and satisfactory wound when it has been resutured after the rupture has taken place? Some Iight is shed on this subject by the recent work of Freeman5 and King,‘j who showed in a series of experiments that the responsibIe factor consists of a IocaI condition. Freeman reports the resuIts of his experiments in which a piece of omentum was aIIowed to protrude through an opening in the peritoneum between the muscIes and under the fascia. In a number of cases he found faiIure of union of the muscIe and fascia. His expIanation appears rationa and Iogicai: the protruding omentum, as a resuIt of pressure, becomes congested and hence increases in size. It then acts as a wedge, and any increase in intra-abdomina1 pressure (especiaIIy in the presence of infection and during the time when the wound heaIing is stiI1 incomplete) wiI1 push the piece of omentum through the incision and force it open. King, in a study of postoperative hernis, (which may be Iooked upon as an incompIete rupture of a wound), comes to a simiIar concIusion, nameIy, that the underIying factor is an opening in the peritoneum into which the abdomina1 viscera find a passage. He concIudes that evisceration is a resuIt of increased intraabdomina1 pressure pIus an incompIeteIy heaIed wound. To compIicate matters stiI1 more as far as this theory is concerned, there arises If the condition is as another question. King and Freeman maintain-a IocaI one due to imperfect cIosure or heaIing of the peritoneum-why does it not occur more frequentIy in those cases where wounds are drained intraperitoneaIIy, especiaIIy where they are deIiberateIy Ieft open and packed, as is so frequentIy done in cases of far advanced appendicea1 infections. However, in a series of experiments on rabbits, the author has deIiberateIy Ieft a smaI1 opening in the peritoneum, otherwise cIosing the abdomina1 wound firmIy and fuIIy. WhiIe these experiments are stiI1
New SERIES VOL. XXXIX,
No. 3
Kross-Evisceration
under way and not yet compIeted, it has been observed in a sufficient number of instances that, at the site of the deIiberateIy made opening, an evisceration took pIace and the intestine was found protruding through the opening, whiIe the rest of the wound was fuIIy heaIed. In considering a11 these factors, one must concIude that no singIe condition by itseIf is soIeIy responsibIe for a11cases of evisceration. This compIication is brought on by a combination of events, in which any singIe one may by itseif be insuffIcient, but when combined with others may produce wound rupture. The resuIts of the experiments of Freeman, King, and the author, and the frequent findings of a partia1 wound rupture with heaIing of the rest of the wound, justify the assumption that in a11 probabiIity the one most important factor is a defect in the cIosure of the peritoneum. As far as prevention of wound rupture is concerned, a11 the theories discussed have a practica1 vaIue, which can be summarized as foIIows: I. The genera1 condition of the patient shouId be brought up to the highest point possibIe, so that the constitutiona factors involved in wound heaIing shouId be at an optimum IeveI. 2. Asepsis shouId be maintained most strictIy in order to reduce the exudative
American Journal of Surgery
613
period to a minimum, and to aIIow the reparative stage to be begun as earIy as possibIe. 3. SpeciaI care shouId be given to the patient to avoid a11 unnecessary increase in intra-abdomina1 pressure due to gastric or intestina1 distention, by earIy use of the Levin tube, recta1 tube and enemata; to avoid or reduce cough by administration of puImonary sedatives; and to avoid restIessness by administration of cerebrospina sedatives. Last and probably most important, meticuIous care should be given to an exact and thorough cIosure of the wound, with specia1 regard to the use of oniy an essentia1 minimum of suture materia1. Care in appIying both sutures and Iigatures is necessary to avoid stranguIation of tissues. I wish to thank Dr. H. E. Isaacs, Dr. I. C. Rubin, and Dr. M. Robinson for their kindness in granting me the privilege of studying the cases from their services. REFERENCES 1. 2.
3. 4. 5. 6. 7.
HOWES, E. L. .%rg. Gynec. e- Ok., 57: 309, 1933. MELENEY, F. L. and HOWES, E. L. Ann. Surg., 99: 5% 1934. COLP, R. Ann. Sutg., 99: 14, 1934. SOKOLOW, S. Vestrick Cbir., 65: 219, 1931. FREEMAN, L. Arch. Sutg., 14: 605, 1927. KING, E. S. &it. J. Surg., 23: 35, 1935. GRACE, R. V. Ann. Surg., 99: 28, 1934.
Surgeon, City Hospital;
POST OPERATIVE kIDOR KROSS, M.D., P.A.C.S. Associate Attending NEW
A
YORK
COMPLICATION
Surgeon, Beth Israel and Montefiore
Hospitals
CITY
N investigation was made of the post- for peIvic operations, showed rupture of the operative eviscerations that oc- wound in eIeven instances where fibroids curred in the surgica1 and gynecowere removed and in no instance where the IogicaI services of the Beth IsraeI HospitaI more frequent adnexal operation was from 1930 to 1936. By evisceration is performed, This may be due to the debiIity meant, in this report, not onIy wound rup- and asthenia brought on by the bIeeding ture, but aIso an accompanying protrusion which is so common a factor in fibroids. of omentum or intestine. During this period TABLE I No. of Cases 4,433 abdomina1 operations (not incIuding Age 2 20-29 inguina1 or femora1 hernias, or suprapubic 7 30-39 prostatectomies) were performed, and evis40-49 ‘5 12 ceration occurred in forty-four of these 50-59 60-69 4 cases. The frequency of occurrence was 70 and over 3 just a fraction more than I per cent. Sex TABLE II apparentIy pIayed no rBIe as an etioIogic Day of Rupture No. of Cases I factor, since twenty-four of these occurred 3 4 in the femaIe patients, and twenty in the ; 5 maIe. Since the gynecoIogica1 patients were 6 9 incIuded in this series, the sIight pres’ 8’ ponderance among the femaIes is thus 4 9 readiIy accounted for. 10 3 I II Numerous investigations have been made I2 1 and reports on the frequency of this compIication have been pubIished, but there is Before discussing the various theories of stiI1 Iacking a satisfactory expIanation for the etioIogy of evisceration, it wouId be its causation and deveIopment. The theoheIpfu1 to review briefly the manner of ries generaIIy advanced are: (I) faiIure of wound heaIing. This wiI1 heIp to expIain the suture materia1; (2) unusua1 strains; the frequency with which this accident (3) constitutiona factors, i.e., asthenia and occurs between the fourth and the eighth debiIity causing a faiIure of the heaIing post-operative days. Wound heaIing was studied in detai1 by MeIeney and Howes.‘f2 process; and (4) wound infection. In this series, the age of the patient did These investigators divide the process into not seem to pIay any rGIe, as the major part two stages, the first or exudative stage of the hospita1 popuIation was between the Iasting four or five days, and the second or third and fifth decades. The character of reparative stage beginning at the end of the incision itseIf has no important part the first stage and continuing unti1 the in this condition, and it is we11known that wound is fuIIy heaIed. There is no sharp, the frequency of wound rupture is about sudden demarcation between the two the same in most cIinics, in spite of the processes; the second stage begins before fact that the character of the incision in the first is fuIIy compIeted. In the first these different cIinics varies considerabIy. period an exudate develops. The character It is aIso interesting to note that the and extent of this phenomenon depends median suprapubic incision which is used upon severa factors: the number of dead 610
NEW SERIES VOL. XXXIX,
No.
3
Kross-Evisceration
and injured ceIIs, the amount of extravasated bIood and Iymph, the presence of dust and bacteria in the wound, and the amount of suture materia1 empIoyed. During this period, the tensiIe strength of the sutures diminishes rapidIy and the hoIding power of the tissues becomes Iess. During the second period, the strength of the wound increases rapidIy as a resuIt of the deveIopment of fibropIasia with uItimate scar formation. At this time the exudate undergoes absorption. The duration of the first period depends upon the character and extent of the exudate. Tissue necrosis and inflammation not onIy increase the duration of this period, but also deIay the beginning of the reparative or second stage, thus causing tissue strength to be gained more sIowIy. Since a11sutures act as foreign bodies, the quantity of suture materia1 and its buIk are important factors in the heaIing process. The tightness with which the tissues are coapted, and the tightness with which sutures and Iigatures are tied, have a direct bearing on the amount of tissue necrosis that takes pIace. This factor, which is so frequentIy overIooked, pIays a considerabIe rBIe in wound heaIing. In a series of experiments on stomach wounds in rats, Howes2 showed definiteIy that a11wounds, after the first day, steadiIy Iost strength up to the fourth day. From then on the wounds began to increase in strength, and after about the seventh day the tensiIe strength of the wound was such that when force was appIied by distending the stomach, rupture occurred in the tissues around the wound and not in the wound itseIf. Up to this time, the same force caused rupture to take pIace at the site of the wound proper. Howes aIso showed that with the use of siIk sutures, the first stage was of shorter duration than with catgut, and aIso that the reparative stage began earIier, proceeded more rapidIy and reached its greatest strength sooner. He aIso demonstrated that the exudate Iasted Ionger and that the deveIopment of the coIIagen fibers began Iater in the wounds where catgut was empIoyed.
American Journal of Surgery
611
As evidence in favor of the theory of failure of the suture materia1 itseIf, numerous exampIes have been pubIished in which at secondary operation no trace of the suture materia1 couId be found. There is no doubt thit this expIanation may account for some cases where there is a combination of severa factors, such as premature absorption of catgut or tearing of catgut, in the first few days after operation before tissue heaIing has advanced perceptibIy, accompanied by sudden increase in intraabdomina1 pressure, especiaIIy in the presence of infection. Inspection of TabIe II, however, shows that many cases occur when tissue heaIing is quite advanced, where there is no evidence of premature absorption of catgut, and where there is no evidence of infection. In one case, evisceration occurred aIthough the suture materia1 consisted of unabsorbabIe siIkworm gut. CoIp,3 who reported the resuIts of a thorough investigation of these cases at the Mount Sinai HospitaI, hoIds that the primary disease is. undoubtedIy the most important factor in the production of evisceration. It is aIs interesting to note that SokoIow,4 who aIso hoIds this view, caIIed attention to the frequency with which wound rupture occurred among the northern peopIe, especiaIIy in the earIy part of the year. This he ascribed to the Iack of vitamin C and to the genera1 fatigue at the end of the very Iong winters in northern countries. From the nature of the diseases for which operation was instituted, it seems to be apparant that debiIitating conditions constitute a frequent and common association with wound rupture. (TabIe III.) In addition to the genera1 asthenia and its interference with norma wound heaIing, Grace’ considers sudden increase in intraabdomina1 pressure to be the direct and most frequent cause of wound rupture. That there is this reIationship can be seen both from the tabIes he shows in his pubIication and aIso from the post-operative factors tending to sudden increase in the intra-abdomina1 pressure, as shown
612
Kross-Evisceration
American Journalof Surgery
in the study IV.) It is not report that immediateIy sneezing.
of this series of cases. (TabIe uncommon for the patient to he feIt something give way after a speI1 of coughing or TABLE III
Nature of Disease Carcinoma Stomach........................ Colon.......................... Pancreas........................ Liver.. .. Rectum......................... Gall-bladder.. Uterine fibroids.. Biliary system.. . Peptic ulcer.. . . Acute appendicitis. IntestinaI adhesions.. Intestinal obstruction., Tuberculosis of cecum.. Hydatid mole.
No. 5 4
1 I I I II
.‘. .
8 5
.
z .
.
2
.. . ..
I I
.
I
TABLE IV
Post-operative CompIications Vomiting. . . . . Restlessness.. . . Distention. . . Cough. . . .. Belching. . .
No.
. 26 20
.
Ig
.
Nausea...........................
Retching..
.
16
. . .
I2 II 7
In view of the usua1 suddenness and unexpectedness of the evisceration, it is worth whiIe emphasizing a cIinica1 observation which in many instances gave warning of an impending and as yet unrecognized evisceration. This was the presence of a dressing saturated with bIoody serum. This occurred in twenty-four cases of the present series. (TabIe v.) TABLE v Day of Appearance No. of Cases Post-Operative 2 4 2 : 7 s’ IO II
5 5 2 I
In considering the theory that genera1 constitutiona factors are responsibIe for this condition, two questions immediateIy come to the fore. How can one expIain the fact that the rupture so frequentIy occurs in one part of the wound onIy, when the rest of the incision has heaIed
MARCH,1938
firmIy and fuIIy? Again, how, on the basis of this theory, can one expIain the firm heaIing of the same and satisfactory wound when it has been resutured after the rupture has taken place? Some Iight is shed on this subject by the recent work of Freeman5 and King,‘j who showed in a series of experiments that the responsibIe factor consists of a IocaI condition. Freeman reports the resuIts of his experiments in which a piece of omentum was aIIowed to protrude through an opening in the peritoneum between the muscIes and under the fascia. In a number of cases he found faiIure of union of the muscIe and fascia. His expIanation appears rationa and Iogicai: the protruding omentum, as a resuIt of pressure, becomes congested and hence increases in size. It then acts as a wedge, and any increase in intra-abdomina1 pressure (especiaIIy in the presence of infection and during the time when the wound heaIing is stiI1 incomplete) wiI1 push the piece of omentum through the incision and force it open. King, in a study of postoperative hernis, (which may be Iooked upon as an incompIete rupture of a wound), comes to a simiIar concIusion, nameIy, that the underIying factor is an opening in the peritoneum into which the abdomina1 viscera find a passage. He concIudes that evisceration is a resuIt of increased intraabdomina1 pressure pIus an incompIeteIy heaIed wound. To compIicate matters stiI1 more as far as this theory is concerned, there arises If the condition is as another question. King and Freeman maintain-a IocaI one due to imperfect cIosure or heaIing of the peritoneum-why does it not occur more frequentIy in those cases where wounds are drained intraperitoneaIIy, especiaIIy where they are deIiberateIy Ieft open and packed, as is so frequentIy done in cases of far advanced appendicea1 infections. However, in a series of experiments on rabbits, the author has deIiberateIy Ieft a smaI1 opening in the peritoneum, otherwise cIosing the abdomina1 wound firmIy and fuIIy. WhiIe these experiments are stiI1
New SERIES VOL. XXXIX,
No. 3
Kross-Evisceration
under way and not yet compIeted, it has been observed in a sufficient number of instances that, at the site of the deIiberateIy made opening, an evisceration took pIace and the intestine was found protruding through the opening, whiIe the rest of the wound was fuIIy heaIed. In considering a11 these factors, one must concIude that no singIe condition by itseIf is soIeIy responsibIe for a11cases of evisceration. This compIication is brought on by a combination of events, in which any singIe one may by itseif be insuffIcient, but when combined with others may produce wound rupture. The resuIts of the experiments of Freeman, King, and the author, and the frequent findings of a partia1 wound rupture with heaIing of the rest of the wound, justify the assumption that in a11 probabiIity the one most important factor is a defect in the cIosure of the peritoneum. As far as prevention of wound rupture is concerned, a11 the theories discussed have a practica1 vaIue, which can be summarized as foIIows: I. The genera1 condition of the patient shouId be brought up to the highest point possibIe, so that the constitutiona factors involved in wound heaIing shouId be at an optimum IeveI. 2. Asepsis shouId be maintained most strictIy in order to reduce the exudative
American Journal of Surgery
613
period to a minimum, and to aIIow the reparative stage to be begun as earIy as possibIe. 3. SpeciaI care shouId be given to the patient to avoid a11 unnecessary increase in intra-abdomina1 pressure due to gastric or intestina1 distention, by earIy use of the Levin tube, recta1 tube and enemata; to avoid or reduce cough by administration of puImonary sedatives; and to avoid restIessness by administration of cerebrospina sedatives. Last and probably most important, meticuIous care should be given to an exact and thorough cIosure of the wound, with specia1 regard to the use of oniy an essentia1 minimum of suture materia1. Care in appIying both sutures and Iigatures is necessary to avoid stranguIation of tissues. I wish to thank Dr. H. E. Isaacs, Dr. I. C. Rubin, and Dr. M. Robinson for their kindness in granting me the privilege of studying the cases from their services. REFERENCES 1. 2.
3. 4. 5. 6. 7.
HOWES, E. L. .%rg. Gynec. e- Ok., 57: 309, 1933. MELENEY, F. L. and HOWES, E. L. Ann. Surg., 99: 5% 1934. COLP, R. Ann. Sutg., 99: 14, 1934. SOKOLOW, S. Vestrick Cbir., 65: 219, 1931. FREEMAN, L. Arch. Sutg., 14: 605, 1927. KING, E. S. &it. J. Surg., 23: 35, 1935. GRACE, R. V. Ann. Surg., 99: 28, 1934.