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Little used surgical techniques of value
Little Used Surgical Techniques of Value
Harris B Shumacker, Jr., MD, Bethesda, Maryland
When a new technique is developed or an existing one modified, the surgeon is faced with a decision and sometimes a dilemma. Should he try it, or should he continue with an older method of management which in his hands and according to his assessment has proven satisfactory, good, or excellent? To choose between two or more alternatives is seldom easy and sometimes difficult. If there are no truly persuasive reasons for a change, the natural tendency is to stay with one’s customary method. Such a decision seems correct. At times, however, and I fear too often, the judgment to stick with the status quo is based on a failure to view the new proposal in a receptive, open-minded way. Has it been given a fair break, with all its possible advantages allowed full weight? Innovations of real promise are often rejected or sparsely utilized because of such considerations. I shall discuss three techniques which, according to my observations and reasoning, are employed too little-two which might have wide and one relatively limited applicability. Others might have been selected. These will, however, serve as examples to point out that more extensive use of certain technical suggestions would be wise and that many benefits have been overlooked or downgraded while too much importance has been attached to possible adverse consequences. Unfortunately, though some of the factors involved are factual, others are only impressions. It is impossible to assign them meaningful numbers so they can be evaluated by a mathematical formula or computer analysis, even if we could assume that such calculations invariably provide the right answers. It is true that anecdotal experiences and “customary” methods may lead one astray if they are followed blindly, for example, blood-letting and the use of the cautery for control of bleeding from severed large blood vessels. It is equally true, howFrom the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Requests for reprints should be addressed to Harris B Shumacker, Jr., MD, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20614. Presented at the 10th Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 1-4, 1962.
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ever, that personal and collective experiences, ongoing or retrospective, often lead to correct assumptions. It required no prospective, randomized, controlled study to establish the fact that Halsted’s gentle, careful, hemostatic operative technique was better than the cruder methods used before. To make the search for the right choice all the more troublesome is the necessity of taking into account the importance of each individual’s background experience and capability. One must also keep in mind that such judgments can never be entirely freed from personal preferences and even prejudices. Despite these intrinsic difficulties which will be minimized as much as possible, the discussion should serve a useful purpose. Gastrostomy Although successful gastrostomy was performed more than 100 years ago, and although sporadic recommendations for tube gastrostomy as a decompressive measure under limited conditions had appeared in the literature from time to time, Farris and Smith’s 1956 report [I] first clearly pointed out its widespread applicability as a substitute for postoperative nasogastric gastrointestinal suction. What advantages does it have? It is easily performed, adds only a few minutes to the length of the operation, and if properly done is as nearly free of associated problems as any minor surgical manipulation can be. It is practically always applicable, and if it is not because of some anatomic condition such as total gastrectomy, a similar end can generally be achieved by means of jejunostomy. It ordinarily causes the patient no discomfort of consequence, in marked contrast to the great annoyance associated with a nasogastric tube. Unusually small nares do not obviate or add difficulty to its use or to the resultant discomfort, as is true of transnasal tubes. Gastrostomy allows freer movement and turning, and reduces the need for nursing care. It eliminates the excessive nasal, oral, pharyngeal, and laryngeal secretions associated with an indwelling catheter. Consequently, it decreases the likelihood of pulmonary complications. In contrast to the method it supersedes, it is entirely free of nasal, pharyngeal, and laryngeal ulcerations and their resultant scarring. It causes no gastric reflux, esophagitis, or strictures. From time to time postnasogastric tube esophageal strictures not amenable to dilatation and requiring major operative revision were
The American Journal of Surgery
Little Used Surgical Techniques
referred to my department at Indiana University. Some of them had developed after only a few days of an indwelling tube, refuting the widely held belief that this complication follows only prolonged use. Identical experiences have been encountered in other tertiary referral centers. The gastrostomy tube can be clamped and left in place as long as it is deemed desirable without adding days of misery, as is usually the case with the alternative method. If one’s judgment has been in error and suction drainage must be reinstituted, one need only remove the clamp and reconnect the tube. The same error with nasogastric decompression necessitates the uncomfortable reinsertion of the tube. When no longer needed, the gastrostomy catheter is easily and comfortably removed and almost never does the site of its introduction through the abdominal wall leak or fail to heal promptly. The few comments concerning gastrostomy found in texts and monographs tend to emphasize the fact that most of those who employ it do so upon completion of abdominal operations which are felt likely to be followed by prolonged gastrointestinal atony. Can one judge accurately, however, how long this period will be? Although experienced surgeons can frequently make a reliable estimation, is it not appropriate to ask how often they are wrong? Would not almost all agree that for each patient whose need for decompression proves shorter than predicted, there are 10 or 20 in whom it is longer, often much longer? It is also true that the misery, though of shorter duration, is almost as great in intensity whether the tube is in place for a few days or 8 or 10. When this infrequently discussed technique is reported on, the point is properly made that avoidance of a nasal tube has special rewards in the elderly and the very ill since the complications obviated are particularly hazardous to them. Occasionally, its usefulness in infants and small children is mentioned, citing their tiny nasal passages as one reason. Ill infants and children, like the elderly, are very prone to have as a result of the tube excessive nasopharyngeal secretions, gastric reflux, and their complications. Robert Gross once told me how he considered tube gastrostomy perhaps the most important operative adjuvant in the aftercare of infants and children. In the opinion of those who have used the procedure most frequently, there are practically no disadvantages provided it is performed properly. During the early learning period a few did occur. A rare patient had some gastric bleeding which could nearly always be stopped by simply pulling the balloon more tightly against the abdominal wall, a complication completely eliminated by making sure there is no oozing from the opening in the stomach at the time the tube is introduced. Very rarely the tube migrated downstream, pulling the external portion near or into the abdominal incision, but never when it was anchored firmly to the skin by appropriate sutures and tape. Very rarely also, leakage occurred about the gastrostomy site, easily managed in practically all instances by snugging the balloon closer to the abdominal wall or exchanging the catheter for one with a larger balloon. Once in a while after withdrawal of the tube some external gastric drainage persisted, especially if an unnecessarily large tube had been used. This almost invariably ceased without intervention. All of these difficulties appear to have been eliminated by correct performance of gastrostomy tube insertion, Some surgeons have feared that opening the stomach might increase the likelihood of intraabdominal infection. I know IIO data to substantiate this concern and I am unaware of
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its having occurred in my own cases. During vascular operations, it has been my custom to extraperitonealize any arterial graft utilized or any vessel opened beforehand, just as it has been in case some additional intraperitoneal procedure was to be carried out such as cholecystectomy. Such experiences in the hands of those who have employed gastrostomy most justify the conclusion that if properly performed it is safe and for all practical purposes free of complications. Is it then employed as often as it should be? The contents of a dozen surgical textbooks and monographs selected at random suggest not. Some do not mention gastrostomy as a replacement for the postoperative nasogastric tube at all, others mention it in passing, while a few devote a short paragraph to it. The most thorough discussion in the volurnes examined is that of Woodward [2]. The initial sentence sets the tone for what follows: “Temporary gastrostomy should be used when prolonged gastrointestinal dysfunction is anticipated, is a likely possibility or would be particularly hazardous.” Reference has been made to the difficulty of making such predictions. The author continues his account by citing age as an important determining factor, and by pointing out advantages of the use of gastrostomy decompression. In the same manual in another chapter dealing with problems of infants and children, Kiesewetter [3] states, “The smaller the child, the more imperative it is to undertake this through an intermittent nasogastric tube insertion, rather than the continuance of a tube which may well interfere with the child’s breathing and cause respiratory complications. Of late, it has been desirable in upper gastrointestinal surgery to use a gastrostomy as a means of decompression prior to its use as a means for feeding.” If many textbooks and other reports fail to advocate postoperative gastrostomy decompression with enthusiasm, conversations with surgeons at home and abroad provide no more support. Far more patients are managed by nasogastric tubes about which they generally complain a great deal more than about incisional pain, intravenous lines, urinary catheter drainage, early mobilization, and other features of the postoperative period. My own experiences, which are entirely retrospective, are extensive, cover a period of about 25 years, and are practically uniform. No patient has voiced objection to the gastrostomy tube; all have been grateful for it. Perhaps the most appropriate remarks, as well as the most forceful support, come from those who have endured a nasogastric tube after one or more previous operations. Even if these procedures were of considerably less magnitude, their response is almost invariably the same: “This is nothing compared with the others.” When asked why this is so they reply, “Because I don’t have that -tube in my nose.” All these considerations lead me to the conclusion that one should place a gastrostomy tube in all abdominal procedures in which a nasogastric tube would otherwise be used.
Extraperitoneal Approach For Vascular Operations When on November 14,1950, Oudot [4] first utilized an aortic bilateral external iliac homograft in a reparative procedure for obliterative disease, the importance of the accomplishment itself drew attention away from the incisional approach employed in carrying it out. The same
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was true of Dubost et al [5] when they reported
4 months later the initial excision of an infrarenal aortic aneurysm, with maintenance of luminal continuity in similar fashion. Both had been carried out through an extraperitoneal approach. When similar operative procedures became more or less commonplace during the following years, they were almost always done transperitoneally. The extraperitoneal approach was by no means new [6]. Sir Astley Cooper [7] had employed it through a suprainguinal incision in 1808 in performing ligation of an iliac artery as had Abernathy and several others. During the nearly 175 years since then a wide variety of incisions have been proposed which now make possible adequate exposure of and operative procedures on all segments of the abdominal aorta, its branches, and the iliac arteries [8-131. What are the advantages of the extraperitoneal approach? It is the method of choice in the very ill and elderly, in those with serious associated diseases, and when previous abdominal operations have been performed. It is much better tolerated than its transabdominal counterpart. This is especially evident in patients with markedly impaired respiratory function who often glide through the postoperative course amazingly well and, against anticipated odds, with little or no ventilatory support. The operation is usually easier and quicker to perform than the transperitoneal. Upon abdominal entry one does not have to bother with the adhesions ordinarily present if a previous operation has been carried out. Once the dissection is completed, the exposure is better and provides more room for necessary reparative work since no pads and packs are required. Appropriate gentle retraction of the peritoneal envelope covering the intraabdominal viscera suffices. Obesity is not a contraindication but constitutes a lesser handicap than with transabdominal procedures. Excessively fat mesentery is out of sight and out of the way. Closure of the incision is simple and speedy since the intact peritoneum prevents abdominal contents from pushing their way into the incision. There is general agreement that patients have a far more comfortable and shorter convalescence. Most surgeons who operate in this manner have found no gastrointestinal decompression necessary. Abdominal discomfort is less. Many patients equate their recovery from resection of a large aortic aneurysm with that from a previous inguinal herniorrhaphy or appendectomy. Breathing is easier and patients are less bothered with nasopharyngeal secretions, cough, hiccups, and urinary and colonic elimination, They generally begin ambulation the evening of operation or the next day and are discharged in a week. The operator has available a variety of incisions to fit the operative requirements. For distal external iliac exposure, the ancient Cooper approach or a modification of it is splendid. For other iliac procedures the anterior musclesplitting approach proposed for sympathectomy is adecurate. For aortoiliac lesions. including distal aortic aneurysms of moderate size, the extended operation of Rob [II], including division of the rectus muscle and sheath, is excellent, as is that of Helsby and Moosa [13] in which a long sickle-shaped incision is made, the external oblique split fully, and the mid-portion of the internal oblique and transversalis divided. For operations requiring exposure of the upper aorta and its visceral branches, one can use the thoracoabdominal operation of Dubost and Shumacker’s
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midline technique. Furthermore, and to great advantage, all the approaches in use are extensile. If one or both distal external iliacs must be utilized, one can expose the appropriate area through a small muscle-splitting approach. Should the simple Flothow-Pearl anterior muscle-splitting incision not prove entirely satisfactory, it can be lengthened posteriorly and anteriorly by transecting part or all of the rectus. Similarly, the Rob approach can be extended any desired distance across the midline. That of Helsby and Moosa can provide better working room if brought upward as far as possible, if the partially divided internal oblique and transversalis are incised as much as is required, and if desired the lower part of the incision can be curved to the right so the rectus can be transected.* With the midline incision, one can gain additional working room for the diaphragmatic part of the abdominal and the distal thoracic aorta by adding the Wangensteen [14] mid-sternal split up to the desired interspace with extrapleural division of the left half, or both halves of the sternum, and even more if the central diaphragm is also divided down to the aortic hiatus. The abdominal incision can be converted into a thoracoabdominal one. Quite a few are using Dubost’s thoracoabdominal approach+ with various modifications not only for abdominal operations but for distal thoracic and thoracoabdominal lesions as well. Whether such incisions are entirely or partly extraperitoneal, they offer similar technical advantages since all the intraperitoneal contents can be retracted to the right behind the peritoneum. There are a few disadvantages, some imagined or debatable. The most concrete failing, more theoretical than practical, lies in the inability to carry out exploration of the abdominal cavity and its contents. If there exist, however, any pathologic conditions other than that for which the operation is being performed, they are usually apparent from history, examination, relatively simple studies or, if necessary, from a host of new ancillary diagnostic aids. In addition, two other considerations must be taken into account. Most, though not necessarily the majority of those with the greatest experience in vascular surgery, believe it unwise to combine a vascular procedure with any other but choose instead to take care of them at separate operations. In the second place, should one see or feel behind the peritoneal envelope anything suggesting the need for investigation or treatment, this can be accomplished simply by opening the peritoneum, visualizing it, biopsying it, and resecting it or leaving it alone according to one’s best judgment. Those who do not employ the extraperitoneal approach apparently have difficulty visualizing the ease of its use and the good exposure it provides. It does require a learning period-brief for the adept, a bit longer for operators of average skill, perhaps a fruitless effort for the clumsy. It is easiest to begin to develop the retroperitoneal space in
* The extended “nephrectomy” incision of Williams et al (Surgery 1980;88:846-55) might also be mentioned. Although it permits operations on the renal vessels and infrarenal aorta, the right iliac is difficult or impossible to dissect free. Better exposure of the pelvic vessels could be obtained by extending the incision downward and to the right as far as or beyond the midline. t Although Oudot’s approach gave “refatively good” exposure of the upper part of the aorta, it was “not perfect,” while Dubost’s gave “the necessary exposure of the aortic bifurcation and the origin of the renal arteries.”
The American
Journal of Surgery
Little Used Surgical Techniques
the left pelvic area, and extend it upward and over to the right pelvic region. Often the beginner and occasionally the more experienced surgeon inadvertently tears a hole in the peritoneum. If one moves away from this area, separates the peritoneum from the overlying structures in the surrounding regions, and gradually moves toward the tear, one avoids enlarging it and mobilizes it so that its closure is easy. It is obvious from texts, monographs, and reports as well as from personal observations that the extraperitoneal approach, though used fairly extensively for iliac vascular procedures, is employed far too infrequently for procedures involving the aorta and its visceral branches. As is true of most operative maneuvers, it should not be used routinely but rather selectively. Just as it is clearly the approach of choice in certain circumstances, so it should not be used in others such as cases of ruptured aneurysm or when some o-ther intraabdominal procedure is also planned.
Permanent Ascending Aortic to Distal Aortic Bypass On July 151959, a 15 year old boy admitted to the hospital with an established diagnosis of coarctation, patent ductus, aneurysm, and hemolytic staphylococcus aureus septicemia was treated urgently because of rapid expansion of a ductal pulsating hematoma and total loss of left lung function by excision of the coarctation, insertion of an aortic graft, and pneumonectomy, all bronchi being plugged by clot. Well periods alternated with episodes of recurrent bacteremia until April 5, 1960, when sudden disruption of the aortic graft suture lines with production of a huge infected pulsating hematoma forced me and my associate, King, to perform a new procedure, one we should have carried out as the initial operation had we conceived of it then. A large graft was attached to the ascending aorta, brought through the opened pericardium and central diaphragm to the aortic hiatus, and anastomosed extrapleurally to the distal thoracic aorta. The incision was repaired after dividing the arch beyond the left carotid, after which the original thoracotomy incision was opened, the graft and clot were removed, and the aortic ends were closed. Although the patient looked well afterwards, he suddenly died from exsanguination on the second day [IS]. Experiments in dogs demonstrated the ease of performing the procedure and excellent appearance of the grafts 9 months later [16]. Experience with use of this bypass has been reported by Eiobinson et al [17], Siderys et al [18], Frantz et al [19], Dubost and Carpentier [20], Cooley et al [21], and Poulias et al [22]. Of these, Dubost and Cooley have used it most frequently. The method, though applicable only in selected cases limited in number, has advantages. It is not difficult to perform. It permits use of as large a graft as is felt desirable since inflow attachment is to the ascending aorta. Many technical variations are possible. The graft may be placed anterior to or within the pericardial sac. The diaphragm may be opened by dividing it in the midline back to the aortic hiatus, splitting the crus toward the left, or wherever the operator chooses. The distal thoracic aorta can be brought into view and worked upon with ease. The upper abdominal aorta is exposed and dissected free without trouble. The lower end of the graft can be attached wher-
Volume 144. August 1982
ever it is thought indicated: to the distal thoracic aorta, the upper abdominal aorta proximal to the origin of the main visceral branches, the infrarenal aorta, both the infrarenal and suprarenal segments, or the iliacs or femorals. It can be passed anterior to the diaphragm, stomach, and transverse colon, placed to the left of these structures by dividing the triangular ligament of the liver, or positioned in the abdomen totally in the retroperitoneal space or substantially so. My preference to open the pericardium and the central diaphragm and attach the distal end of the graft as proximally as the existing disease permits from the supradiaphragmatic descending thoracic aorta downward, keeping it extrapleural and as completely retroperitoneal as possible. The procedure can be employed in a wide variety of conditions: coarctation with dense diffuse pleural adhesions or periaortic scarring resulting from disease or previous operative repair and recurrence, interrupted aortic arch, and such lesions associated with intracardiac ones requiring surgical treatment. It is useful in unusual instances of abdominal aortic coarctation and abdominal aortoiliac obliterative and hypoplastic disease, in secondary operations on the aorta rendered difficult and hazardous by perivascular fibrosis, and in large thoracic aneurysms either primary or secondary to dissection felt unsuitable for treatment in the usual way because of anatomic considerations or the patient’s condition. After establishing the bypass the aneurysm can be left in place with proximal occlusion or entrapment, or it can be excised totally or in part with closure of the aortic ends. The distal arch or the first part of the descending thoracic aorta can be divided or otherwise closed through the mediastinotomy incision. Additional work in the left hemithorax can be accomplished through an intercostal incision extending from the divided sternum or through a separate thoracotomy. The grafting procedure makes unnecessary the very troublesome att.achment of the graft to the enlarged diaphragmatic end of an aneurysm, which is particularly difficult when one is dealing with a dissecting aneurysm and must close the split aortic wall as well. It is the best way to deal with cases with infection in the left hemithorax since it provides a clean, large, extraanatomic pathway which can be completed before entering the contaminated left chest. Disadvantages of the technique are not related to the method of bypass but to its use when other procedures might be more appropriate. The graft from the ascending aorta ha,s been anastamosed to the femoral arteries and even the profunda femorals. The graft would better be brought down from the descending thoracic aorta in such cases [23,24]. Although use of this procedure is restricted to unusual cases, its wider application is justified and it can render safer and easier otherwise hazardous and difficult procedures.
Summary Discussion of the pros and cons of a few operative techniques leads to the conclusion that they deserve wider use, currently restricted by failure to appreci-
ate demonstrated advantages, by exaggeration of potential or known disadvantages, and by the common policies of “letting well enough alone” and of “following the herd.”
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Shumacker
References 1. Farris JM, Smith EK. An evaluation of temporary gastrostomy as a substitute for nasogastric suction. Ann Surg 1956; 144~475-86. 2. Woodward ER. The stomach and duodenum. In: Kinney JM, Egdahl RH, Zuidema GD, eds. Manual of preoperative and postoperative care. American College of Surgeons. Philadelphia: WB Saunders, 1971:340-l. 3. Kiesewetter WB. Problems of infants and children. In Ref 2: 290. 4. Oudot J. La greffe vasculaire dans les thromboses du carrefour aortique. Presse Med 1951;59:234-6. 5. Dubost C, Allary M, Deconomos N. Resection of an aneurysm of the abdominal aorta. Reestablishment of the continuity by a preserved human arterial graft with result after five months. Arch Surg 1952;64:405-8. 6. Shumacker HB Jr. Extraperitoneal exposure for vascular operations in retrospect. South Med J (in press). 7. Cooper A. Case of femoral aneurysm for which the external iliac artery was tied by Sir Astley Cooper, Bt. An account of the preparation of the limb, disse.cted at the expiration of eighteen years. Taken from Sir Astley Cooper’s notes. Guy’s Hosp Rep 1836;1:43-52. 8. Murray G. Aortic embolectomy. Surg Gynecol Obstet 1943; 77:157-62. 9. Flothow PG. Anterior extraperitoneal approach to the lumbar sympathetic nerves. Am J Surg 1935;29:23-5. 10. Pearl FL. Muscle-splitting extraperitoneal lumbar ganglionectomy. Surg Gynecol Obstet 1937;65: 107- 12. 11. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963:53:87-g. 12. Shumacker HB Jr. Midline exposure of the abdominal aorta and iliacs. Surg Gynecol Obstet 1972;135:791-2. 13. Helsby R, Moosa AR. Aortic-iliac reconstruction with special
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14.
15.
16. 17. 18.
19.
20.
2 1.
22.
23. 24.
reference to the extraperitoneal approach. Br J Surg 1975;62:596-9. Wangensteen OH. A physiologic operation for mega-esophagus (dystonia, cardiospasm, achalasia). Ann Surg 1951; 134: 301-18. Shumacker HB Jr, King H. Surgical management of rapidly expanding intrathoracic pulsating hematomas. Surg Gynecol Obstet 1959; 109: 155-64. Jontz JG, King H, Shumacker HB Jr. Permanent bypass grafting of the thoracic aorta. Arch Surg 1960;80:578-9. Robinson G, Siegelman S. Attai L. Recurrent dissecting aneurysms of the aorta. NY State Med J 1972;72:2328-31. Siderys H, Graffis R, Halbrook H, Kasbeckar V. A technique for management of inaccessible coarctation of the aorta. J Thorac Cardiovasc Surg 1974;67:568-70. Frantz SL, Kaplitt M, Beil HR. Stein HL. Ascending aorta-bilateral femoral artery bypass for totally occluded infrarenal aorta. Surgery 1974;75:471-5. Dubost C, Carpentier A. Acualites de chirurgie cardio-vasculaire de I’hopital Broussais. Chirurgie vasculaire. Paris: Masson, 1979:25-66. Wukasch DP, Cooley DA, Sandiford FM, Nappi G, Reul GJ Jr. Ascending aorta-abdominal aorta bypass: indications, technique and report of 12 patients. Ann Thorac Surg 1977;23:442-8. Poulias GE, Polemis L, Skoutas B, Kavetsos G, Doundoulakis N, Sendekeya S. Generalized hypoplastic aortopathy, successfully treated by ascending aorto-iliac bypass. Case report with eight years follow-up. J Cardiovasc Surg 1982; 22:528-30. DeBakey ME. Basic concepts of therapy in arterial disease. NY Acad Med 1963;39:707-49. Nunn DB, Kamal MA. Bypass grafting from the thoracic aorta to femoral arteries for high aortoiliac occlusive disease. Surgery 1972;72:749-55.
The American Journal of Surgery
Harris B Shumacker, Jr., MD, Bethesda, Maryland
When a new technique is developed or an existing one modified, the surgeon is faced with a decision and sometimes a dilemma. Should he try it, or should he continue with an older method of management which in his hands and according to his assessment has proven satisfactory, good, or excellent? To choose between two or more alternatives is seldom easy and sometimes difficult. If there are no truly persuasive reasons for a change, the natural tendency is to stay with one’s customary method. Such a decision seems correct. At times, however, and I fear too often, the judgment to stick with the status quo is based on a failure to view the new proposal in a receptive, open-minded way. Has it been given a fair break, with all its possible advantages allowed full weight? Innovations of real promise are often rejected or sparsely utilized because of such considerations. I shall discuss three techniques which, according to my observations and reasoning, are employed too little-two which might have wide and one relatively limited applicability. Others might have been selected. These will, however, serve as examples to point out that more extensive use of certain technical suggestions would be wise and that many benefits have been overlooked or downgraded while too much importance has been attached to possible adverse consequences. Unfortunately, though some of the factors involved are factual, others are only impressions. It is impossible to assign them meaningful numbers so they can be evaluated by a mathematical formula or computer analysis, even if we could assume that such calculations invariably provide the right answers. It is true that anecdotal experiences and “customary” methods may lead one astray if they are followed blindly, for example, blood-letting and the use of the cautery for control of bleeding from severed large blood vessels. It is equally true, howFrom the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Requests for reprints should be addressed to Harris B Shumacker, Jr., MD, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20614. Presented at the 10th Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 1-4, 1962.
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ever, that personal and collective experiences, ongoing or retrospective, often lead to correct assumptions. It required no prospective, randomized, controlled study to establish the fact that Halsted’s gentle, careful, hemostatic operative technique was better than the cruder methods used before. To make the search for the right choice all the more troublesome is the necessity of taking into account the importance of each individual’s background experience and capability. One must also keep in mind that such judgments can never be entirely freed from personal preferences and even prejudices. Despite these intrinsic difficulties which will be minimized as much as possible, the discussion should serve a useful purpose. Gastrostomy Although successful gastrostomy was performed more than 100 years ago, and although sporadic recommendations for tube gastrostomy as a decompressive measure under limited conditions had appeared in the literature from time to time, Farris and Smith’s 1956 report [I] first clearly pointed out its widespread applicability as a substitute for postoperative nasogastric gastrointestinal suction. What advantages does it have? It is easily performed, adds only a few minutes to the length of the operation, and if properly done is as nearly free of associated problems as any minor surgical manipulation can be. It is practically always applicable, and if it is not because of some anatomic condition such as total gastrectomy, a similar end can generally be achieved by means of jejunostomy. It ordinarily causes the patient no discomfort of consequence, in marked contrast to the great annoyance associated with a nasogastric tube. Unusually small nares do not obviate or add difficulty to its use or to the resultant discomfort, as is true of transnasal tubes. Gastrostomy allows freer movement and turning, and reduces the need for nursing care. It eliminates the excessive nasal, oral, pharyngeal, and laryngeal secretions associated with an indwelling catheter. Consequently, it decreases the likelihood of pulmonary complications. In contrast to the method it supersedes, it is entirely free of nasal, pharyngeal, and laryngeal ulcerations and their resultant scarring. It causes no gastric reflux, esophagitis, or strictures. From time to time postnasogastric tube esophageal strictures not amenable to dilatation and requiring major operative revision were
The American Journal of Surgery
Little Used Surgical Techniques
referred to my department at Indiana University. Some of them had developed after only a few days of an indwelling tube, refuting the widely held belief that this complication follows only prolonged use. Identical experiences have been encountered in other tertiary referral centers. The gastrostomy tube can be clamped and left in place as long as it is deemed desirable without adding days of misery, as is usually the case with the alternative method. If one’s judgment has been in error and suction drainage must be reinstituted, one need only remove the clamp and reconnect the tube. The same error with nasogastric decompression necessitates the uncomfortable reinsertion of the tube. When no longer needed, the gastrostomy catheter is easily and comfortably removed and almost never does the site of its introduction through the abdominal wall leak or fail to heal promptly. The few comments concerning gastrostomy found in texts and monographs tend to emphasize the fact that most of those who employ it do so upon completion of abdominal operations which are felt likely to be followed by prolonged gastrointestinal atony. Can one judge accurately, however, how long this period will be? Although experienced surgeons can frequently make a reliable estimation, is it not appropriate to ask how often they are wrong? Would not almost all agree that for each patient whose need for decompression proves shorter than predicted, there are 10 or 20 in whom it is longer, often much longer? It is also true that the misery, though of shorter duration, is almost as great in intensity whether the tube is in place for a few days or 8 or 10. When this infrequently discussed technique is reported on, the point is properly made that avoidance of a nasal tube has special rewards in the elderly and the very ill since the complications obviated are particularly hazardous to them. Occasionally, its usefulness in infants and small children is mentioned, citing their tiny nasal passages as one reason. Ill infants and children, like the elderly, are very prone to have as a result of the tube excessive nasopharyngeal secretions, gastric reflux, and their complications. Robert Gross once told me how he considered tube gastrostomy perhaps the most important operative adjuvant in the aftercare of infants and children. In the opinion of those who have used the procedure most frequently, there are practically no disadvantages provided it is performed properly. During the early learning period a few did occur. A rare patient had some gastric bleeding which could nearly always be stopped by simply pulling the balloon more tightly against the abdominal wall, a complication completely eliminated by making sure there is no oozing from the opening in the stomach at the time the tube is introduced. Very rarely the tube migrated downstream, pulling the external portion near or into the abdominal incision, but never when it was anchored firmly to the skin by appropriate sutures and tape. Very rarely also, leakage occurred about the gastrostomy site, easily managed in practically all instances by snugging the balloon closer to the abdominal wall or exchanging the catheter for one with a larger balloon. Once in a while after withdrawal of the tube some external gastric drainage persisted, especially if an unnecessarily large tube had been used. This almost invariably ceased without intervention. All of these difficulties appear to have been eliminated by correct performance of gastrostomy tube insertion, Some surgeons have feared that opening the stomach might increase the likelihood of intraabdominal infection. I know IIO data to substantiate this concern and I am unaware of
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its having occurred in my own cases. During vascular operations, it has been my custom to extraperitonealize any arterial graft utilized or any vessel opened beforehand, just as it has been in case some additional intraperitoneal procedure was to be carried out such as cholecystectomy. Such experiences in the hands of those who have employed gastrostomy most justify the conclusion that if properly performed it is safe and for all practical purposes free of complications. Is it then employed as often as it should be? The contents of a dozen surgical textbooks and monographs selected at random suggest not. Some do not mention gastrostomy as a replacement for the postoperative nasogastric tube at all, others mention it in passing, while a few devote a short paragraph to it. The most thorough discussion in the volurnes examined is that of Woodward [2]. The initial sentence sets the tone for what follows: “Temporary gastrostomy should be used when prolonged gastrointestinal dysfunction is anticipated, is a likely possibility or would be particularly hazardous.” Reference has been made to the difficulty of making such predictions. The author continues his account by citing age as an important determining factor, and by pointing out advantages of the use of gastrostomy decompression. In the same manual in another chapter dealing with problems of infants and children, Kiesewetter [3] states, “The smaller the child, the more imperative it is to undertake this through an intermittent nasogastric tube insertion, rather than the continuance of a tube which may well interfere with the child’s breathing and cause respiratory complications. Of late, it has been desirable in upper gastrointestinal surgery to use a gastrostomy as a means of decompression prior to its use as a means for feeding.” If many textbooks and other reports fail to advocate postoperative gastrostomy decompression with enthusiasm, conversations with surgeons at home and abroad provide no more support. Far more patients are managed by nasogastric tubes about which they generally complain a great deal more than about incisional pain, intravenous lines, urinary catheter drainage, early mobilization, and other features of the postoperative period. My own experiences, which are entirely retrospective, are extensive, cover a period of about 25 years, and are practically uniform. No patient has voiced objection to the gastrostomy tube; all have been grateful for it. Perhaps the most appropriate remarks, as well as the most forceful support, come from those who have endured a nasogastric tube after one or more previous operations. Even if these procedures were of considerably less magnitude, their response is almost invariably the same: “This is nothing compared with the others.” When asked why this is so they reply, “Because I don’t have that -tube in my nose.” All these considerations lead me to the conclusion that one should place a gastrostomy tube in all abdominal procedures in which a nasogastric tube would otherwise be used.
Extraperitoneal Approach For Vascular Operations When on November 14,1950, Oudot [4] first utilized an aortic bilateral external iliac homograft in a reparative procedure for obliterative disease, the importance of the accomplishment itself drew attention away from the incisional approach employed in carrying it out. The same
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was true of Dubost et al [5] when they reported
4 months later the initial excision of an infrarenal aortic aneurysm, with maintenance of luminal continuity in similar fashion. Both had been carried out through an extraperitoneal approach. When similar operative procedures became more or less commonplace during the following years, they were almost always done transperitoneally. The extraperitoneal approach was by no means new [6]. Sir Astley Cooper [7] had employed it through a suprainguinal incision in 1808 in performing ligation of an iliac artery as had Abernathy and several others. During the nearly 175 years since then a wide variety of incisions have been proposed which now make possible adequate exposure of and operative procedures on all segments of the abdominal aorta, its branches, and the iliac arteries [8-131. What are the advantages of the extraperitoneal approach? It is the method of choice in the very ill and elderly, in those with serious associated diseases, and when previous abdominal operations have been performed. It is much better tolerated than its transabdominal counterpart. This is especially evident in patients with markedly impaired respiratory function who often glide through the postoperative course amazingly well and, against anticipated odds, with little or no ventilatory support. The operation is usually easier and quicker to perform than the transperitoneal. Upon abdominal entry one does not have to bother with the adhesions ordinarily present if a previous operation has been carried out. Once the dissection is completed, the exposure is better and provides more room for necessary reparative work since no pads and packs are required. Appropriate gentle retraction of the peritoneal envelope covering the intraabdominal viscera suffices. Obesity is not a contraindication but constitutes a lesser handicap than with transabdominal procedures. Excessively fat mesentery is out of sight and out of the way. Closure of the incision is simple and speedy since the intact peritoneum prevents abdominal contents from pushing their way into the incision. There is general agreement that patients have a far more comfortable and shorter convalescence. Most surgeons who operate in this manner have found no gastrointestinal decompression necessary. Abdominal discomfort is less. Many patients equate their recovery from resection of a large aortic aneurysm with that from a previous inguinal herniorrhaphy or appendectomy. Breathing is easier and patients are less bothered with nasopharyngeal secretions, cough, hiccups, and urinary and colonic elimination, They generally begin ambulation the evening of operation or the next day and are discharged in a week. The operator has available a variety of incisions to fit the operative requirements. For distal external iliac exposure, the ancient Cooper approach or a modification of it is splendid. For other iliac procedures the anterior musclesplitting approach proposed for sympathectomy is adecurate. For aortoiliac lesions. including distal aortic aneurysms of moderate size, the extended operation of Rob [II], including division of the rectus muscle and sheath, is excellent, as is that of Helsby and Moosa [13] in which a long sickle-shaped incision is made, the external oblique split fully, and the mid-portion of the internal oblique and transversalis divided. For operations requiring exposure of the upper aorta and its visceral branches, one can use the thoracoabdominal operation of Dubost and Shumacker’s
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midline technique. Furthermore, and to great advantage, all the approaches in use are extensile. If one or both distal external iliacs must be utilized, one can expose the appropriate area through a small muscle-splitting approach. Should the simple Flothow-Pearl anterior muscle-splitting incision not prove entirely satisfactory, it can be lengthened posteriorly and anteriorly by transecting part or all of the rectus. Similarly, the Rob approach can be extended any desired distance across the midline. That of Helsby and Moosa can provide better working room if brought upward as far as possible, if the partially divided internal oblique and transversalis are incised as much as is required, and if desired the lower part of the incision can be curved to the right so the rectus can be transected.* With the midline incision, one can gain additional working room for the diaphragmatic part of the abdominal and the distal thoracic aorta by adding the Wangensteen [14] mid-sternal split up to the desired interspace with extrapleural division of the left half, or both halves of the sternum, and even more if the central diaphragm is also divided down to the aortic hiatus. The abdominal incision can be converted into a thoracoabdominal one. Quite a few are using Dubost’s thoracoabdominal approach+ with various modifications not only for abdominal operations but for distal thoracic and thoracoabdominal lesions as well. Whether such incisions are entirely or partly extraperitoneal, they offer similar technical advantages since all the intraperitoneal contents can be retracted to the right behind the peritoneum. There are a few disadvantages, some imagined or debatable. The most concrete failing, more theoretical than practical, lies in the inability to carry out exploration of the abdominal cavity and its contents. If there exist, however, any pathologic conditions other than that for which the operation is being performed, they are usually apparent from history, examination, relatively simple studies or, if necessary, from a host of new ancillary diagnostic aids. In addition, two other considerations must be taken into account. Most, though not necessarily the majority of those with the greatest experience in vascular surgery, believe it unwise to combine a vascular procedure with any other but choose instead to take care of them at separate operations. In the second place, should one see or feel behind the peritoneal envelope anything suggesting the need for investigation or treatment, this can be accomplished simply by opening the peritoneum, visualizing it, biopsying it, and resecting it or leaving it alone according to one’s best judgment. Those who do not employ the extraperitoneal approach apparently have difficulty visualizing the ease of its use and the good exposure it provides. It does require a learning period-brief for the adept, a bit longer for operators of average skill, perhaps a fruitless effort for the clumsy. It is easiest to begin to develop the retroperitoneal space in
* The extended “nephrectomy” incision of Williams et al (Surgery 1980;88:846-55) might also be mentioned. Although it permits operations on the renal vessels and infrarenal aorta, the right iliac is difficult or impossible to dissect free. Better exposure of the pelvic vessels could be obtained by extending the incision downward and to the right as far as or beyond the midline. t Although Oudot’s approach gave “refatively good” exposure of the upper part of the aorta, it was “not perfect,” while Dubost’s gave “the necessary exposure of the aortic bifurcation and the origin of the renal arteries.”
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Little Used Surgical Techniques
the left pelvic area, and extend it upward and over to the right pelvic region. Often the beginner and occasionally the more experienced surgeon inadvertently tears a hole in the peritoneum. If one moves away from this area, separates the peritoneum from the overlying structures in the surrounding regions, and gradually moves toward the tear, one avoids enlarging it and mobilizes it so that its closure is easy. It is obvious from texts, monographs, and reports as well as from personal observations that the extraperitoneal approach, though used fairly extensively for iliac vascular procedures, is employed far too infrequently for procedures involving the aorta and its visceral branches. As is true of most operative maneuvers, it should not be used routinely but rather selectively. Just as it is clearly the approach of choice in certain circumstances, so it should not be used in others such as cases of ruptured aneurysm or when some o-ther intraabdominal procedure is also planned.
Permanent Ascending Aortic to Distal Aortic Bypass On July 151959, a 15 year old boy admitted to the hospital with an established diagnosis of coarctation, patent ductus, aneurysm, and hemolytic staphylococcus aureus septicemia was treated urgently because of rapid expansion of a ductal pulsating hematoma and total loss of left lung function by excision of the coarctation, insertion of an aortic graft, and pneumonectomy, all bronchi being plugged by clot. Well periods alternated with episodes of recurrent bacteremia until April 5, 1960, when sudden disruption of the aortic graft suture lines with production of a huge infected pulsating hematoma forced me and my associate, King, to perform a new procedure, one we should have carried out as the initial operation had we conceived of it then. A large graft was attached to the ascending aorta, brought through the opened pericardium and central diaphragm to the aortic hiatus, and anastomosed extrapleurally to the distal thoracic aorta. The incision was repaired after dividing the arch beyond the left carotid, after which the original thoracotomy incision was opened, the graft and clot were removed, and the aortic ends were closed. Although the patient looked well afterwards, he suddenly died from exsanguination on the second day [IS]. Experiments in dogs demonstrated the ease of performing the procedure and excellent appearance of the grafts 9 months later [16]. Experience with use of this bypass has been reported by Eiobinson et al [17], Siderys et al [18], Frantz et al [19], Dubost and Carpentier [20], Cooley et al [21], and Poulias et al [22]. Of these, Dubost and Cooley have used it most frequently. The method, though applicable only in selected cases limited in number, has advantages. It is not difficult to perform. It permits use of as large a graft as is felt desirable since inflow attachment is to the ascending aorta. Many technical variations are possible. The graft may be placed anterior to or within the pericardial sac. The diaphragm may be opened by dividing it in the midline back to the aortic hiatus, splitting the crus toward the left, or wherever the operator chooses. The distal thoracic aorta can be brought into view and worked upon with ease. The upper abdominal aorta is exposed and dissected free without trouble. The lower end of the graft can be attached wher-
Volume 144. August 1982
ever it is thought indicated: to the distal thoracic aorta, the upper abdominal aorta proximal to the origin of the main visceral branches, the infrarenal aorta, both the infrarenal and suprarenal segments, or the iliacs or femorals. It can be passed anterior to the diaphragm, stomach, and transverse colon, placed to the left of these structures by dividing the triangular ligament of the liver, or positioned in the abdomen totally in the retroperitoneal space or substantially so. My preference to open the pericardium and the central diaphragm and attach the distal end of the graft as proximally as the existing disease permits from the supradiaphragmatic descending thoracic aorta downward, keeping it extrapleural and as completely retroperitoneal as possible. The procedure can be employed in a wide variety of conditions: coarctation with dense diffuse pleural adhesions or periaortic scarring resulting from disease or previous operative repair and recurrence, interrupted aortic arch, and such lesions associated with intracardiac ones requiring surgical treatment. It is useful in unusual instances of abdominal aortic coarctation and abdominal aortoiliac obliterative and hypoplastic disease, in secondary operations on the aorta rendered difficult and hazardous by perivascular fibrosis, and in large thoracic aneurysms either primary or secondary to dissection felt unsuitable for treatment in the usual way because of anatomic considerations or the patient’s condition. After establishing the bypass the aneurysm can be left in place with proximal occlusion or entrapment, or it can be excised totally or in part with closure of the aortic ends. The distal arch or the first part of the descending thoracic aorta can be divided or otherwise closed through the mediastinotomy incision. Additional work in the left hemithorax can be accomplished through an intercostal incision extending from the divided sternum or through a separate thoracotomy. The grafting procedure makes unnecessary the very troublesome att.achment of the graft to the enlarged diaphragmatic end of an aneurysm, which is particularly difficult when one is dealing with a dissecting aneurysm and must close the split aortic wall as well. It is the best way to deal with cases with infection in the left hemithorax since it provides a clean, large, extraanatomic pathway which can be completed before entering the contaminated left chest. Disadvantages of the technique are not related to the method of bypass but to its use when other procedures might be more appropriate. The graft from the ascending aorta ha,s been anastamosed to the femoral arteries and even the profunda femorals. The graft would better be brought down from the descending thoracic aorta in such cases [23,24]. Although use of this procedure is restricted to unusual cases, its wider application is justified and it can render safer and easier otherwise hazardous and difficult procedures.
Summary Discussion of the pros and cons of a few operative techniques leads to the conclusion that they deserve wider use, currently restricted by failure to appreci-
ate demonstrated advantages, by exaggeration of potential or known disadvantages, and by the common policies of “letting well enough alone” and of “following the herd.”
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References 1. Farris JM, Smith EK. An evaluation of temporary gastrostomy as a substitute for nasogastric suction. Ann Surg 1956; 144~475-86. 2. Woodward ER. The stomach and duodenum. In: Kinney JM, Egdahl RH, Zuidema GD, eds. Manual of preoperative and postoperative care. American College of Surgeons. Philadelphia: WB Saunders, 1971:340-l. 3. Kiesewetter WB. Problems of infants and children. In Ref 2: 290. 4. Oudot J. La greffe vasculaire dans les thromboses du carrefour aortique. Presse Med 1951;59:234-6. 5. Dubost C, Allary M, Deconomos N. Resection of an aneurysm of the abdominal aorta. Reestablishment of the continuity by a preserved human arterial graft with result after five months. Arch Surg 1952;64:405-8. 6. Shumacker HB Jr. Extraperitoneal exposure for vascular operations in retrospect. South Med J (in press). 7. Cooper A. Case of femoral aneurysm for which the external iliac artery was tied by Sir Astley Cooper, Bt. An account of the preparation of the limb, disse.cted at the expiration of eighteen years. Taken from Sir Astley Cooper’s notes. Guy’s Hosp Rep 1836;1:43-52. 8. Murray G. Aortic embolectomy. Surg Gynecol Obstet 1943; 77:157-62. 9. Flothow PG. Anterior extraperitoneal approach to the lumbar sympathetic nerves. Am J Surg 1935;29:23-5. 10. Pearl FL. Muscle-splitting extraperitoneal lumbar ganglionectomy. Surg Gynecol Obstet 1937;65: 107- 12. 11. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963:53:87-g. 12. Shumacker HB Jr. Midline exposure of the abdominal aorta and iliacs. Surg Gynecol Obstet 1972;135:791-2. 13. Helsby R, Moosa AR. Aortic-iliac reconstruction with special
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reference to the extraperitoneal approach. Br J Surg 1975;62:596-9. Wangensteen OH. A physiologic operation for mega-esophagus (dystonia, cardiospasm, achalasia). Ann Surg 1951; 134: 301-18. Shumacker HB Jr, King H. Surgical management of rapidly expanding intrathoracic pulsating hematomas. Surg Gynecol Obstet 1959; 109: 155-64. Jontz JG, King H, Shumacker HB Jr. Permanent bypass grafting of the thoracic aorta. Arch Surg 1960;80:578-9. Robinson G, Siegelman S. Attai L. Recurrent dissecting aneurysms of the aorta. NY State Med J 1972;72:2328-31. Siderys H, Graffis R, Halbrook H, Kasbeckar V. A technique for management of inaccessible coarctation of the aorta. J Thorac Cardiovasc Surg 1974;67:568-70. Frantz SL, Kaplitt M, Beil HR. Stein HL. Ascending aorta-bilateral femoral artery bypass for totally occluded infrarenal aorta. Surgery 1974;75:471-5. Dubost C, Carpentier A. Acualites de chirurgie cardio-vasculaire de I’hopital Broussais. Chirurgie vasculaire. Paris: Masson, 1979:25-66. Wukasch DP, Cooley DA, Sandiford FM, Nappi G, Reul GJ Jr. Ascending aorta-abdominal aorta bypass: indications, technique and report of 12 patients. Ann Thorac Surg 1977;23:442-8. Poulias GE, Polemis L, Skoutas B, Kavetsos G, Doundoulakis N, Sendekeya S. Generalized hypoplastic aortopathy, successfully treated by ascending aorto-iliac bypass. Case report with eight years follow-up. J Cardiovasc Surg 1982; 22:528-30. DeBakey ME. Basic concepts of therapy in arterial disease. NY Acad Med 1963;39:707-49. Nunn DB, Kamal MA. Bypass grafting from the thoracic aorta to femoral arteries for high aortoiliac occlusive disease. Surgery 1972;72:749-55.
The American Journal of Surgery