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Use of muscle flaps for reconstruction after head and neck surgery for cancer
Use of Muscle Flaps for Reconstruction after Head
and Neck Surgery
for Cancer
OLIVER S. MOORE, M.D. AND ANAXAGORAS N. PAPAIOANNOU, M.D.,* iVm
From the Head and Neck Service of the Memorial SloalzKettering Cancer Center, New York, New York.
THE PROCESS of a difficult wound closure after resection of a bulky posterior lesion of the tongue, one of US (0. M.) utilized the levator scapulae muscle to support the pharyngeal closure by transecting its distal end and transplanting it anteriorly after adequate mobilization. The postoperative course was uncomplicated and an improved postoperative cosmetic result was also achieved incidentally. (Fig. 1 and 2.) This procedure was first performed in Memorial Hospital in September 1959. Since then we have used the levator scapulae as well as other muscles for various purposes in over
I
N
fifty patients with cancer of the head and neck, with satisfactory results. We have found only a casual reference to this technic in the literature [1,2]. We therefore wish to report our experience with this useful method which may be applied for many purposes after radical neck dissection usually combined with mandibulectomy or excision of the intraoral primary lesion and marginal resection of the mandible and tracheostomy (Commando operation) [3]. THE TECHNIC AND ITS APPLICATION The levator scapulae is the most suitable muscle to use for all purposes because of its adequate width and length and its ability to maintain good blood supply if properly handled.
2
1
FIG. 1 and 2. Levator scapulae muscle filling defect produced of the mandible and reinforcing oral-pharyngeal suture line. * PRESENT ADDRESS: Department
York, New York
by resection
of Surgery, Albert Einstein College of Medicine,
514
Bronx, New York. American
Journal
of Surgery
Muscle
Flaps in Reconstruction
FIG. 3. Sites of muscle division at completion
after Cancer Surgery
of neck dissection and resection of mandible.
FIG. 4. Levator scapulae muscle used to buttress suture line and help fill space after neck dissection and resection of mandible and floor of mouth.
In addition, the strap, trapezius and cervicis muscles may be used either alone or in combination with the levator scapulae, depending upon the need and anatomic setting in each case. We have generally employed muscle flaps for the following purposes: (1) To cover the carotid bulb or carotid arteries when a fistula is likely (Fig. 5) ; (2) to support a closure that is under tension or is in an irradiated field; (3) to provide soft tissue coverage in wire reconstruction of partially resected mandible; (4) to buttress a suture line and fill a dead space; (5) to improve the cosmetic result after operation and (6) for a combination of the above. The levator scapulae muscle is transected as near its origin as possible and by gently mobilizing it from its bed by blunt finger dissection, the desired length may be obtained. The muscle belly is then rotated and sutured in place. An occasional supporting suture may be used along the course of the flap. (Fig. 3 and 4.) The mobilized muscle has a width to length ratio ranging from 1: 4 to 1: 6 and it is obviously denervated but with adequate blood supply. Figures 3 and 4 show schematically the steps of transecting, mobilizing, and suturing in place the levator scapulae and strap muscles to fill in the defect produced by a commando procedure. Vol. 110, October 1965
It is important that the viability of the entire rotated end of the muscle be ascertained. The muscle is mobilized after the neck dissection specimen is removed and then left to lie in the wound while the surgeon is occupied with tying of bleeders, etc. Inspection of the muscle flap will occasionally reveal varied degrees of duskiness of the edges of the flap, which, if it
FIG. 5. Levator scapulae covering pharyngeal suture line after laryngectomy and protecting carotid bulb area.
Moore
and Papaioannou
occurs, is usually fairly well demarcated from the normal-looking muscle. These areas should be excised. Suction catheters are routinely left in the wound for drainage. We have found the application of pressure dressing to be unnecessary in the presence of effective suction. RESULTS
The procedure was used for coverage of a wire prosthesis in four patients and for coverage of a Teflon@ arterial graft in one. In the remaining patients muscle flaps were used for the protection of the carotid bulb and artery or support and buttress of a pharyngeal or oral closure. In one such case, a draining sinus in the floor of the mouth developed due to necrosis of the end of the rotated levator scapulae muscle. The sinus closed after through and through drainage and debridement of the necrotic muscle edge. This delayed the patient’s discharge by approximately ten days. The functional and cosmetic results were considered as satisfactory in all but two cases which we considered as failures and are dealt with in detail as follows : CASE REPORTS CASE I. This sixty-six year old white man (0. H.) developed metastatic carcinoma in the lymph nodes of the right midneck from an undetermined primary site in January 1963. He was treated elsewhere by x-ray, receiving 3,100 r tumor dose through a large port over the left neck with the 250 kv. machine, completed in July 1963. On admission to Memorial Hospital in October 1963, palpable lymph node metastases were present at the upper and midjugular levels. Painstaking search failed to reveal the primary site. On October 23, 1963 right radical neck dissection was performed along with resection of the superior laryngeal and vagus nerves, as well as resection of the carotid bulb, internal and external carotid arteries. A Teflon graft was used to anastomose common and upper end of internal carotid arteries and the levator scapulae and longus coli muscles were used to cover the graft and the vascular anastomoses. Extensive lymph node metastases were found in the specimen. Necrosis of the skin flaps ensued; the levator scapulae appeared ischemic and the carotid artery and graft became eventually exposed. Whereas good blood flow was initially achieved, a carotid arteriogram made one week later showed complete occlusion of the graft. There had been no neurologic sequelae. On November 8, 1963 the necrotic tissues were debrided, the Teflon graft removed, the common and internal carotid arteries
ligated, and the wound was allowed to granulate. The wound was eventually skin grafted and the patient was discharged forty-eight days after the initial procedure. CASE II. This forty-seven year old white man (B. J.) had the diagnosis of epidermoid carcinoma of the left tonsil made elsewhere in June 1963, and received 4,700 r through a lateral 6 by 8 inch port with the cobalt 60 machine. Local recurrence and left neck lymph node metastases were observed eight weeks later and he was given an additional 900 r through the same port. This treatment was stopped owing to local skin reaction and another 3,900 r were given to the left tonsillar area through a slightly oblique anterior port. Three weeks later recurrence was again noted. When he was admitted to Memorial Hospital in December 1963, he had marked local pain with complete trismus that prevented examination of the oral cavity. There were postradiation skin changes but no palpable nodes in the neck. On December 31, 1963 he underwent a left tonsil commando along with resection of the left side of the soft and hard palate, left maxillectomy, left lateral partial pharyngectomy, and left partial glossectomy. The levator scapulae and strap muscles were used along with a dermal graft to cover the entire carotid artery and pharyngeal closure. Extensive osteonecrosis of the mandible and metastatic epidermoid carcinoma in the upper jugular lymph nodes were found in the specimen. Wound breakdown was noted the fifth postoperative day; the levator scapulae appeared ischemic and twelve days later, when a carotid blowout became imminent, the carotid artery was ligated above the clavicle and at the base of the skull and the wound was debrided, leaving a large lateral pharyngeal defect. No neurologic difficulties ensued. Due to the patient’s complete inability to swahow without aspirating, total laryngectomy was subsequently done. No complications attended this latter operation and the patient was discharged fifty-three days after the original operation. COMMENTS In assessing the value of a procedure, the complications and disadvantages incident to its application must be examined. The possibilities of increased morbidity and deterioration of shoulder function are such considerations. Increase in morbidity may occur, as shown in one of our cases discussed previously, if the end of the rotated muscle flap becomes necrotic. As previously mentioned, gentle handling crushing instruwith the fingers, avoiding ments and observing the circulation of the flap about ten minutes after its final mobilization are all important in preventing ischemia of the Amevican
Journal
of Surgery
Muscle
Flaps
in Reconstruction
after
Cancer
Surgery
-517
transplant. Currently, whenever we definitely contemplate usage of the flap, we transect and mobilize the levator muscle at the end of the neck dissection, wrapping it in gauze wet with normal saline solution, and we use it after thirty to sixty minutes when the entire specimen is removed and reconstruction is begun. If any question of ischemia is raised at this time, the area in question is excised before the flap is sutured in place. Inman, Saunders, and Abbott [a], conducting detailed experiments in living subjects, observed that the levator scapulae acting as one unit along with the trapezius and serratus anterior, shows action potential during rest, suspending the scapula and counteracting the weight of the shoulder. During the elevation of the shoulder in flexion or abduction, their action potential rises synchronously in a linear fashion. After transection of the spinal accessory nerve which is routinely carried out during radical neck dissections in this center, a certain degree of shoulder drop occurs as a result of atrophy of the trapezius. Although in theory the shoulder drop should increase by depriving the suspending action of the levator scapulae, clinically this is not observed. (Fig. 6.) In line with the observations of Inman and his colleagues, it is possible that the muscle complex of trapezius-levator scapulae-serratus anterior, maintains its function as a group to a satisfactory degree even though only one of them may actually be intact. It is interesting that we did not observe any increased difficulties in shoulder function other than those normally expected as a result of the transection of the spinal accessory nerve. We have not had the opportunity to examine any of these muscle flaps at autopsy. It is assumed that such a denervated muscle undergoes atrophy and is largely replaced bv fibrosis. This is unimportant, however, as long as the initial purpose for its application is achieved. In onepatient we had theopportunity toobserve grossly the levator scapulae flap which was used to provide soft tissue coverage of wire prosthesis of the mandible. The muscle flap covered the carotid bulb and adjacent portions of the external and internal carotid arteries. The opportunity was afforded when on the night of the operation, a hematoma developed in the wound. The wound was opened, the blood clot evacuated, but the bleeding point could not be identified and the Vol. 110, October 1965
FIG. 6. Patient illustrating shoulder function ten (lays after neck dissection and resection of right mnndil~le and totlgue primary with levator scapul:~e uwd to rcirlforce sliturc lint
wound was closed. Hematoma recurred the following day and the day after that and was treated in the same fashion except that the wound was packed open after the third evacuation of blood clot. Through this wound opening the rotated levator scapulae could be readily observed. The flap remained viable until the wound opening granulated in and closed spontaneously. Although part of the muscle may undergo fibrosis, some of the bulk of the muscle remains so that the good initial cosmetic result is largely maintained. The muscle flap aids in holding the remaining portion of the mandible in place. Heavy preoperative radiation was given in both cases in which the procedure failed. In the first case a 3.100 r tumor dose was delivered through a very large port over the left side of the neck that extended to the entire supraclavicular area and certainly included in the field at least part of the levator scapulae. In the second case ~,800 r in air was given over the left side of the neck and a total of 9,500 r in air over the tonsillar region, 3,900 of which was administered through an oblique anterior port which may have also delivered radiation to the origin of the levator scapulae. It is therefore probable that the preoperative radiation, part
518
Moore and Papaioannou
of which was also delivered to the levator scapulae, may have contributed to the deterioration of the circulation in the rotated flap. In some of the patients preoperative radiation was given to the primary site and/or neck nodes in doses ranging from 2,000 r to 6,900 r. In one of these patients who received 4,600 r the levator scapulae and the longus coli were used to cover the extensively denuded carotid artery; and although a pharyngeal fistula developed, we consider the muscle flaps as successful in their purpose to prevent exposure of the carotid artery. In another patient who had received 6,900 r tumor dose preoperatively, the levator scapulae and strap muscles were used to cover the carotid artery. An orocutaneous fistula developed, but the integrity of the carotid artery was preserved and we therefore consider this also as a satisfactory result from the viewpoint of fulfillment of the purpose of the flap. The majority of our patients received varied amounts of radiation before operation and muscle flaps were used successfully. It is in this group of patients that the procedure finds one of its most important applications. As one
familiarizes himself with the procedure, the mobilization and suturing of the flap in place takes but a few minutes and is not associated with appreciable blood loss and, if properly executed, is not associated with any added morbidity. SUMMARY
In patients with carcinoma of the head and neck region, various muscle flaps have been utilized to cover large surgical defects to help buttress a suture line, for cosmetic purposes, or to protect the carotid bulb and carotid arteries. The technic and our experience with more than fifty cases are outlined. REFERENCES 1. CARVETH, S. W.,
DEVINE, K. D., and REMINE, W. H. Laryngectomy with radical neck dissection in extensive cancer of the larynx. Am. J. surg., 104: 705, 1962. 2. EDGERTON,M. T. Personal communication, 1964. 3. MARTIN, H. Surgery of the Head and Neck Tumors, 3rd ed., p. 13. New York, 1961. P. B. Hoeber, Inc. 4. INMAN, V. T., SAUNDERS,J. B., de C. M., and ABBOTT, L. C. Observations on the function of the shoulder joint. J. Bone & Joint Surg., 26: 1, 1944.
American
Jouvnal of Surgery
and Neck Surgery
for Cancer
OLIVER S. MOORE, M.D. AND ANAXAGORAS N. PAPAIOANNOU, M.D.,* iVm
From the Head and Neck Service of the Memorial SloalzKettering Cancer Center, New York, New York.
THE PROCESS of a difficult wound closure after resection of a bulky posterior lesion of the tongue, one of US (0. M.) utilized the levator scapulae muscle to support the pharyngeal closure by transecting its distal end and transplanting it anteriorly after adequate mobilization. The postoperative course was uncomplicated and an improved postoperative cosmetic result was also achieved incidentally. (Fig. 1 and 2.) This procedure was first performed in Memorial Hospital in September 1959. Since then we have used the levator scapulae as well as other muscles for various purposes in over
I
N
fifty patients with cancer of the head and neck, with satisfactory results. We have found only a casual reference to this technic in the literature [1,2]. We therefore wish to report our experience with this useful method which may be applied for many purposes after radical neck dissection usually combined with mandibulectomy or excision of the intraoral primary lesion and marginal resection of the mandible and tracheostomy (Commando operation) [3]. THE TECHNIC AND ITS APPLICATION The levator scapulae is the most suitable muscle to use for all purposes because of its adequate width and length and its ability to maintain good blood supply if properly handled.
2
1
FIG. 1 and 2. Levator scapulae muscle filling defect produced of the mandible and reinforcing oral-pharyngeal suture line. * PRESENT ADDRESS: Department
York, New York
by resection
of Surgery, Albert Einstein College of Medicine,
514
Bronx, New York. American
Journal
of Surgery
Muscle
Flaps in Reconstruction
FIG. 3. Sites of muscle division at completion
after Cancer Surgery
of neck dissection and resection of mandible.
FIG. 4. Levator scapulae muscle used to buttress suture line and help fill space after neck dissection and resection of mandible and floor of mouth.
In addition, the strap, trapezius and cervicis muscles may be used either alone or in combination with the levator scapulae, depending upon the need and anatomic setting in each case. We have generally employed muscle flaps for the following purposes: (1) To cover the carotid bulb or carotid arteries when a fistula is likely (Fig. 5) ; (2) to support a closure that is under tension or is in an irradiated field; (3) to provide soft tissue coverage in wire reconstruction of partially resected mandible; (4) to buttress a suture line and fill a dead space; (5) to improve the cosmetic result after operation and (6) for a combination of the above. The levator scapulae muscle is transected as near its origin as possible and by gently mobilizing it from its bed by blunt finger dissection, the desired length may be obtained. The muscle belly is then rotated and sutured in place. An occasional supporting suture may be used along the course of the flap. (Fig. 3 and 4.) The mobilized muscle has a width to length ratio ranging from 1: 4 to 1: 6 and it is obviously denervated but with adequate blood supply. Figures 3 and 4 show schematically the steps of transecting, mobilizing, and suturing in place the levator scapulae and strap muscles to fill in the defect produced by a commando procedure. Vol. 110, October 1965
It is important that the viability of the entire rotated end of the muscle be ascertained. The muscle is mobilized after the neck dissection specimen is removed and then left to lie in the wound while the surgeon is occupied with tying of bleeders, etc. Inspection of the muscle flap will occasionally reveal varied degrees of duskiness of the edges of the flap, which, if it
FIG. 5. Levator scapulae covering pharyngeal suture line after laryngectomy and protecting carotid bulb area.
Moore
and Papaioannou
occurs, is usually fairly well demarcated from the normal-looking muscle. These areas should be excised. Suction catheters are routinely left in the wound for drainage. We have found the application of pressure dressing to be unnecessary in the presence of effective suction. RESULTS
The procedure was used for coverage of a wire prosthesis in four patients and for coverage of a Teflon@ arterial graft in one. In the remaining patients muscle flaps were used for the protection of the carotid bulb and artery or support and buttress of a pharyngeal or oral closure. In one such case, a draining sinus in the floor of the mouth developed due to necrosis of the end of the rotated levator scapulae muscle. The sinus closed after through and through drainage and debridement of the necrotic muscle edge. This delayed the patient’s discharge by approximately ten days. The functional and cosmetic results were considered as satisfactory in all but two cases which we considered as failures and are dealt with in detail as follows : CASE REPORTS CASE I. This sixty-six year old white man (0. H.) developed metastatic carcinoma in the lymph nodes of the right midneck from an undetermined primary site in January 1963. He was treated elsewhere by x-ray, receiving 3,100 r tumor dose through a large port over the left neck with the 250 kv. machine, completed in July 1963. On admission to Memorial Hospital in October 1963, palpable lymph node metastases were present at the upper and midjugular levels. Painstaking search failed to reveal the primary site. On October 23, 1963 right radical neck dissection was performed along with resection of the superior laryngeal and vagus nerves, as well as resection of the carotid bulb, internal and external carotid arteries. A Teflon graft was used to anastomose common and upper end of internal carotid arteries and the levator scapulae and longus coli muscles were used to cover the graft and the vascular anastomoses. Extensive lymph node metastases were found in the specimen. Necrosis of the skin flaps ensued; the levator scapulae appeared ischemic and the carotid artery and graft became eventually exposed. Whereas good blood flow was initially achieved, a carotid arteriogram made one week later showed complete occlusion of the graft. There had been no neurologic sequelae. On November 8, 1963 the necrotic tissues were debrided, the Teflon graft removed, the common and internal carotid arteries
ligated, and the wound was allowed to granulate. The wound was eventually skin grafted and the patient was discharged forty-eight days after the initial procedure. CASE II. This forty-seven year old white man (B. J.) had the diagnosis of epidermoid carcinoma of the left tonsil made elsewhere in June 1963, and received 4,700 r through a lateral 6 by 8 inch port with the cobalt 60 machine. Local recurrence and left neck lymph node metastases were observed eight weeks later and he was given an additional 900 r through the same port. This treatment was stopped owing to local skin reaction and another 3,900 r were given to the left tonsillar area through a slightly oblique anterior port. Three weeks later recurrence was again noted. When he was admitted to Memorial Hospital in December 1963, he had marked local pain with complete trismus that prevented examination of the oral cavity. There were postradiation skin changes but no palpable nodes in the neck. On December 31, 1963 he underwent a left tonsil commando along with resection of the left side of the soft and hard palate, left maxillectomy, left lateral partial pharyngectomy, and left partial glossectomy. The levator scapulae and strap muscles were used along with a dermal graft to cover the entire carotid artery and pharyngeal closure. Extensive osteonecrosis of the mandible and metastatic epidermoid carcinoma in the upper jugular lymph nodes were found in the specimen. Wound breakdown was noted the fifth postoperative day; the levator scapulae appeared ischemic and twelve days later, when a carotid blowout became imminent, the carotid artery was ligated above the clavicle and at the base of the skull and the wound was debrided, leaving a large lateral pharyngeal defect. No neurologic difficulties ensued. Due to the patient’s complete inability to swahow without aspirating, total laryngectomy was subsequently done. No complications attended this latter operation and the patient was discharged fifty-three days after the original operation. COMMENTS In assessing the value of a procedure, the complications and disadvantages incident to its application must be examined. The possibilities of increased morbidity and deterioration of shoulder function are such considerations. Increase in morbidity may occur, as shown in one of our cases discussed previously, if the end of the rotated muscle flap becomes necrotic. As previously mentioned, gentle handling crushing instruwith the fingers, avoiding ments and observing the circulation of the flap about ten minutes after its final mobilization are all important in preventing ischemia of the Amevican
Journal
of Surgery
Muscle
Flaps
in Reconstruction
after
Cancer
Surgery
-517
transplant. Currently, whenever we definitely contemplate usage of the flap, we transect and mobilize the levator muscle at the end of the neck dissection, wrapping it in gauze wet with normal saline solution, and we use it after thirty to sixty minutes when the entire specimen is removed and reconstruction is begun. If any question of ischemia is raised at this time, the area in question is excised before the flap is sutured in place. Inman, Saunders, and Abbott [a], conducting detailed experiments in living subjects, observed that the levator scapulae acting as one unit along with the trapezius and serratus anterior, shows action potential during rest, suspending the scapula and counteracting the weight of the shoulder. During the elevation of the shoulder in flexion or abduction, their action potential rises synchronously in a linear fashion. After transection of the spinal accessory nerve which is routinely carried out during radical neck dissections in this center, a certain degree of shoulder drop occurs as a result of atrophy of the trapezius. Although in theory the shoulder drop should increase by depriving the suspending action of the levator scapulae, clinically this is not observed. (Fig. 6.) In line with the observations of Inman and his colleagues, it is possible that the muscle complex of trapezius-levator scapulae-serratus anterior, maintains its function as a group to a satisfactory degree even though only one of them may actually be intact. It is interesting that we did not observe any increased difficulties in shoulder function other than those normally expected as a result of the transection of the spinal accessory nerve. We have not had the opportunity to examine any of these muscle flaps at autopsy. It is assumed that such a denervated muscle undergoes atrophy and is largely replaced bv fibrosis. This is unimportant, however, as long as the initial purpose for its application is achieved. In onepatient we had theopportunity toobserve grossly the levator scapulae flap which was used to provide soft tissue coverage of wire prosthesis of the mandible. The muscle flap covered the carotid bulb and adjacent portions of the external and internal carotid arteries. The opportunity was afforded when on the night of the operation, a hematoma developed in the wound. The wound was opened, the blood clot evacuated, but the bleeding point could not be identified and the Vol. 110, October 1965
FIG. 6. Patient illustrating shoulder function ten (lays after neck dissection and resection of right mnndil~le and totlgue primary with levator scapul:~e uwd to rcirlforce sliturc lint
wound was closed. Hematoma recurred the following day and the day after that and was treated in the same fashion except that the wound was packed open after the third evacuation of blood clot. Through this wound opening the rotated levator scapulae could be readily observed. The flap remained viable until the wound opening granulated in and closed spontaneously. Although part of the muscle may undergo fibrosis, some of the bulk of the muscle remains so that the good initial cosmetic result is largely maintained. The muscle flap aids in holding the remaining portion of the mandible in place. Heavy preoperative radiation was given in both cases in which the procedure failed. In the first case a 3.100 r tumor dose was delivered through a very large port over the left side of the neck that extended to the entire supraclavicular area and certainly included in the field at least part of the levator scapulae. In the second case ~,800 r in air was given over the left side of the neck and a total of 9,500 r in air over the tonsillar region, 3,900 of which was administered through an oblique anterior port which may have also delivered radiation to the origin of the levator scapulae. It is therefore probable that the preoperative radiation, part
518
Moore and Papaioannou
of which was also delivered to the levator scapulae, may have contributed to the deterioration of the circulation in the rotated flap. In some of the patients preoperative radiation was given to the primary site and/or neck nodes in doses ranging from 2,000 r to 6,900 r. In one of these patients who received 4,600 r the levator scapulae and the longus coli were used to cover the extensively denuded carotid artery; and although a pharyngeal fistula developed, we consider the muscle flaps as successful in their purpose to prevent exposure of the carotid artery. In another patient who had received 6,900 r tumor dose preoperatively, the levator scapulae and strap muscles were used to cover the carotid artery. An orocutaneous fistula developed, but the integrity of the carotid artery was preserved and we therefore consider this also as a satisfactory result from the viewpoint of fulfillment of the purpose of the flap. The majority of our patients received varied amounts of radiation before operation and muscle flaps were used successfully. It is in this group of patients that the procedure finds one of its most important applications. As one
familiarizes himself with the procedure, the mobilization and suturing of the flap in place takes but a few minutes and is not associated with appreciable blood loss and, if properly executed, is not associated with any added morbidity. SUMMARY
In patients with carcinoma of the head and neck region, various muscle flaps have been utilized to cover large surgical defects to help buttress a suture line, for cosmetic purposes, or to protect the carotid bulb and carotid arteries. The technic and our experience with more than fifty cases are outlined. REFERENCES 1. CARVETH, S. W.,
DEVINE, K. D., and REMINE, W. H. Laryngectomy with radical neck dissection in extensive cancer of the larynx. Am. J. surg., 104: 705, 1962. 2. EDGERTON,M. T. Personal communication, 1964. 3. MARTIN, H. Surgery of the Head and Neck Tumors, 3rd ed., p. 13. New York, 1961. P. B. Hoeber, Inc. 4. INMAN, V. T., SAUNDERS,J. B., de C. M., and ABBOTT, L. C. Observations on the function of the shoulder joint. J. Bone & Joint Surg., 26: 1, 1944.
American
Jouvnal of Surgery