Methods for abdominal surgery
From Primary Surgery
Before a major operation
A patient is much more likely to withstand major surgery successfully if he is as fit as he can be to begin with. So do all you can to get him into the best possible condition first. You will not be able to do a thorough workup', but there are things you can do. For example, if you find that he is anaemic, malnourished, or tuberculous, and his operation is not urgent, treat him. Severe malnutrition will greatly reduce his ability to withstand the operation. Above all, don't operate on him while he is still dehydrated[md]this at least you should be able to correct (A 15.3).
Assess his need for surgery, the best time for it, and the risks it will involve. If a particular procedure would be too much for him, you will have to ask yourself if there is a lesser alternative which you could do under local anaesthesia, and what will happen if you do nothing? If there is a choice of procedures, do the simplest and safest one, for example, the insertion of a drainage tube rather than removing his gall bladder (13.17).
Follow these rules: (1) Don't start an operation without thinking it through step by step before you start. (2) Monitor him closely for 48 hours after any emergency or major operation. (3) Prevent the aspiration of stomach contents (A 16.1), and treat respiratory depression (A 3.4) immediately. (4) The most common postoperative complications are respiratory, and the answer to most of them is vigorous coughing (9.11). (5) Learn the basic principles of fluid therapy (A 15.1 to 15.5). (6) The operation may be routine to you, but it is sure to be a major event in his life, so try to establish a good relationship with him and his family. Tell him why you are operating, and give him some idea of what to expect afterwards[md]how much pain he will have, and when he will recover. If you might have to make a colostomy, discuss this with him before you operate. If you promise to close it eventually, be sure to do so.
Most of the major operations you do are likely to be abdominal ones, so here is the routine preoperative care for a patient who is to have a laparotomy.
Fig. 9-1 THE ANTERIOR ABDOMINAL WALL. A, common abdominal incisions. B, the ultimate incision', if you want an extensive exposure. C, the anatomy of the anterior abdominal wall. C, after Maingot R, Abdominal Operations' (4th edn 1961), Fig. 1, HK Lewis, with kind permission.
PREOPERATIVE PREPARATION HISTORY AND EXAMINATION. What previous illnesses has the patient had? Is he taking any drugs? Is he sensitive to anything, particularly to streptomycin, sulphonamides, penicillin, or chloroquin?
Assess his degree of wasting. Ask about a cough, fever, chest pain, dyspnoea, and smoking. How fit is he? Can he climb hills, or do a day's work in the fields? Can he step up and down off a chair for half a minute without becoming short of breath? Or, can he hold his breath for 20 seconds? Look for signs of anaemia. Feel the strength of his grip; this is a good predictor of surgical risk in men, less so in women.
SPECIAL TESTS. Measure his haematocrit or haemoglobin. Test his urine for albumin and sugar, and examine its deposit. This will exclude any serious disease of his urinary tract, and help you to diagnose renal colic, which may present as an acute abdomen. Test his blood group, and if necessary cross-match blood for him. Remember the risk of HIV. If you suspect heart or lung disease, take a chest X-ray.
ASSOCIATED DISEASE. If necessary, and if time allows, try to improve his general health, especially his nutrition and hydration. Look for tuberculosis and chronic renal disease.
If he is malnourished, especially if he is a child, and his disease permits, feed him by mouth or by nasogastic tube, even for as short a period as two weeks before you operate. If he is anorexic, feeding him will be difficult. He may tolerate nasogastric feeding (9.10, 58.11).
If he is febrile, consider the possibility of malaria or typhoid fever, in addition to the possible surgical causes of fever.
If he is anaemic, consider the urgency of the operation in relation to the severity of his anaemia. Most routine' operations can be done with a haemoglobin as low as 80 g/l. It it is 60 or 70 g/l, only do urgent procedures. For example, a woman with haemoglobin of 30 g/l who is bleeding slowly from an ectopic pregnancy can be transfused overnight with 20 ml/kg of blood (from her abdominal cavity if necessary) and given 1 mg/kg of frusemide. If an operation is less urgent, for example a hysterectomy for chronic anaemia due to fibroids, transfuse her 2 or 3 days before you operate. For nonurgent surgery you can take a unit of blood 4 weeks and 2 weeks before a planned major operation, and store them.
If a patient has jaundice, it will greatly increase the risks of surgery, but not operating may be even more dangerous. Give him parenteral vitamin K[,1] for a few days preoperatively. Exclude hepatitis first, especially the acute stage, when anaesthesia can be dangerous.
If he is producing sputum, give him chest physiotherapy and a course of antibiotics prior to surgery if possible. Anaesthetize him appropriately, using local or regional blocks where possible (A 17.8). If he has a common cold, cancel anything but an emergency operation.
CHEST PHYSIOTHERAPY before and after the operation will reduce the risk of lung complications[md]see Section 9.11.
SKIN PREPARATION. If he is very dirty, wash the operation site several times. If he has pustules, boils, or eczematous patches near the site of your proposed incision, treat them before you operate. Bacteria from them may infect the wound, so consider delayed primary closure (9.8).
NASOGASTRIC SUCTION. Insert a nasogastric tube before all stomach or gut operations. The danger of aspiration pneumonitis is even greater if he has intestinal obstruction or ileus.
PERIOPERATIVE ANTIBIOTICS may be lifesaving[md]see Section 2.9.
DON'T OPERATE ON A DEHYDRATED PATIENT
A laparotomy for an acute abdomen will be the major test of your surgical skill. When you decide to do one, you should usually be sure what you will need to do when you get inside it[md]so try to make a correct diagnosis first, and try to avoid a purely exploratory laparotomy'. Before you start, discuss the procedure with him and his family, and if he is to have a colostomy, or a T-tube, make sure they understand it.
Try to avoid wound infections and dehiscence (burst abdomen'), and the incisional hernias that commonly follow them. Make an incision which is big enough to allow you to get at the organs you want to operate on[md]a common mistake is to make it too short. Incisions heal from side-to-side, not from end-to-end, so don't be afraid of making a long one. The length of an incision has little relation to the incidence of operative shock. If an incision is too small: (1) you will not be able to dissect safely, and (2) your assistant will have to exert excessive traction on its edges, which will kill tissue, and increase the risk of wound sepsis and breakdown. A good surgeon makes incisions that are large enough to ensure safe dissection, and does not exhaust his assistants by requiring them to exert forceful traction.
If you separate muscle fibres instead of cutting across them, you help to make a patient's abdomen as strong afterwards as it was before. Avoid cutting his intercostal nerves, because a paralysed abdominal wall is more likely to herniate. Remember that they take an oblique downwards path between his internal oblique and transversus muscles.
Which incision? If possible, make a transverse incision in an infant because it heals better. In an adult a median or paramedian one will enable you to get at everything in the abdomen if you need to. You can make the middle part to begin with, and extend it from his xiphisternum to his pubis, if necessary. If exposure is particularly difficult, you can extend either incision laterally to make a T' incision.
A midline incision above the umbilicus is quick, simple, and bloodless, and is useful for emergency operations. But access to the organs at the sides of a patient's abdomen is not easy, and if you want to extend it around his umbilicus, you have to make a detour which is difficult to sew up nicely. Even so, midline incisions are usually best for trauma, for Caesarean sections, and for most pelvic operations. One contributor felt that they are so much the best, that we should not mention paramedian ones. If you wish, you can always make a midline incision. Above the umiblicus they heal well, as they do below it if you repair them with monofilament as a single layer.
The old type of paramedian incision, in which the rectus muscle was retracted laterally, too often dehisced. The newer rectus-splitting type is less likely to do this, especially if you repair it with monofilament in a single layer.
When you get inside, you will have to decide what to do. Here, only experience can tell you what is normal and what is not. For example, some Ascaris worms inside a child's gut may feel so abnormal as to convince you that they must be the cause of his symptoms, when in fact they are normal for his community.
Be gentle, gut is highly sensitive. If you handle it roughly, especially if it is obstructed, ileus may follow. Gut does not like being frequently drawn out of a wound. So, if you need to draw it out, do so only once, and hold it with a moist swab. While it rests on the abdominal wall, keep it covered with warm moist packs or towels, or place it in a large sterile plastic bag. If it is grossly distended, even the most gentle handling will burst it, so decompress it (10-9). Break down adhesions gently (10-11).
A COMMON ERROR IS TO MAKE THE INCISION TOO SHORT Fig. 9-2 OPENING THE PERITONEAL CAVITY. A, the skin has been incised and the rectus muscle split in the line of its fibres. The posterior rectus sheath and peritoneum form a single layer. Pick this up with a haemostat, and then apply another one 5 mm from it. Release the first haemostat (which might perhaps have picked up gut) and then reapply it. With the peritoneum still tented up, make a small incision between the two haemostats. Air will enter the patient's peritoneal cavity, and his viscera will fall away.
B, put your fingers into the incision to make sure that there are no adhesions to the under surface of his abdominal wall, and then extend it with scissors.
LAPAROTOMY RESUSCITATION. Make sure that the patient has a drip up with a large needle or a cannula. If necessary, splint his arm with an armboard, and tie this to the table. If bleeding is likely to be serious, have some blood cross-matched for him.
X-RAYS. Take these when necessary, and have his films in the theatre.
EQUIPMENT. A general set (4.12). A No. 22 scalpel blade. No. 1 (or 1/0 monofilament used double) for single layer closure. 2/0 monofilament for his skin. 2/0 silk or linen for ligatures. Fine half circle needles with a cutting edge for his skin, and round bodied ones for deeper structures. 2/0 catgut on atraumatic needles for intestinal anastomoses. Gallipots of some soapy solution and alcoholic iodine. Sterile towels and a sheet with a window in it.
ANAESTHESIA. (1) General anaesthesia, preferably with relaxants (A 14.3). (2) Local anaesthesia (6.9). (3) Subarachnoid (spinal) or epidural anaesthesia (A 7.1), provided he is not shocked.
Always pass a nasogastric tube (4.9). Aspirate his stomach contents before you take him to the theatre. If the operation is an emergency, put 30 ml of magnesium trisilicate down the tube to minimize the risk of the acid aspiration syndrome (A 16.3). Spigot it during induction, and aspirate it from time to time during the operation.
If he is gravely ill, from bleeding or infection, local anaesthesia may be safer than a general anaesthetic (A 5.4). Mix 20 ml of 2% lignocaine with 80 ml of saline to give 100 ml of 0.4% solution. To this add 0.5 ml of adrenalin 1:1000. Inject 10 ml of this solution into five sites in his rectus muscle on either side in quantities of 1 ml to block his segmental nerves. Use another 20 ml to infiltrate the midline incision. Use the remaining 10 ml to infiltrate the root of his mesentery if you need to resect his gut. If you have to do some extensive procedure, such as lavaging his abdominal cavity, inject ketamine 1 mg/kg intravenously. Alternatively, and with greater risk, inject pethidine intravenously in SMALL quantities of 5 mg. Patients who are old or shocked or sick, especially if they have been previously sedated, are very sensitive to even modest doses of pethidine, which may produce coma deep enough to need resuscitation. So be prepared to do this if necessary (A 3.4).
POSITION. For most abdominal operations, lie him on his back. If your table does not rotate from side to side, and you want him turned to one side, place pillows under his back on each side, or use a wedge block under the mattress.
If you are operating on his pelvic organs, you will find the Trendelenburg or head-down position helpful. It will allow his gut to fall towards his diaphragm, so that you get a better view into his pelvis. You will need well-padded shoulder rests to prevent him sliding downwards. Don't tip him too steeply, or the pressure on his diaphragm will impair his breathing. If he is in [mt]10[de] of Trendelenburg, you must intubate him, keep him on relaxants, and control his ventilation.
Use one arm for a blood pressure cuff and the other for an intravenous line. Keep his hands by his side, or out on arm boards, or folded on his chest with suitable ties; don't place them under his buttocks or under his head.
EXAMINATION. When he is anaesthetized and relaxed, feel his abdomen carefully. You may get a better appreciation of his abdominal pathology than you could when he was awake.
PREPARATION. See elsewhere for shaving and preparation (2.3). Drape his abdomen and fix the drapes with towel clips. Cover these with a large windowed sheet, and add additional sterile towels as necessary.
WHICH INCISION? (also see above) If you are doing a purely exploratory laparotomy, and don't know what you are going to find, make a midline or rectus-splitting incision in the correct half of his abdomen, upper or lower.
If you are reopening his abdomen, go through the old skin incision. Excise it and extend it so that you can enter his abdominal cavity above or below any adhesions to the under surface of his abdominal wall. Work your way up or down carefully, dividing any adhesions you find, so as not to injure any adherent gut.
CAUTION ! (1) If you are in doubt, make the incision of indecision' in the midline 5 cm above and below his umbilicus. Enter his abdomen and then extend it in the most useful direction. (2) Don't make a second incision parallel to an earlier one, because the tissues between them may necrose.
Before you make any abdominal incision, use the back of your scalpel to make some scratches across it. When you come to sew it up afterwards, these scratches will help you to bring the edges of the skin together accurately. Later, as you gain experience, stop doing this, as it may cause keloids.
MIDLINE INCISION UPPER MIDLINE INCISION. Use his xiphoid and umbilicus as landmarks, keep strictly to the midline, and don't cut into his rectus muscle on either side. It does not matter if you do, except that you may have difficulty approximating the wound edges later.
Cut down to his linea alba and then use the flat of the blade to clear 7 mm on either side, ready for closure later. Cut through his linea alba to expose his extraperitoneal fat. Use gauze dissection to move this to one side.
If necessary, extend the incision downwards. Cut 1.5 cm round his umbilicus[md]don't cut into it[md]it is full of bacteria! You can also get a little more length by incising between his xiphisternum and his costal cartilage.
LOWER MIDLINE INCISION. Make this in a similar way. You will see his pyramidalis muscle at the lower end of the wound. There is no posterior rectus sheath in the lower two-thirds of the wound, below his umbilicus.
Fig. 9-3 A MIDLINE INCISION. A, the site. B, cut down to the linea alba, and then carefully dissect the fat for a centimetre on either side, using the flat of the knife. C, incise the linea alba to expose the underlying fat and peritoneum. D, displace the fat and vessels laterally by blunt gauze dissection. E, pick up the peritoneum, incise it with a knife and split it with blunt- ended scissors. F, if you want to continue the incision downwards, go round the umbilicus. After Dudley HAF, Operative Sugery[md]the abdomen.' Butterworth, Permission requested.
PARAMEDIAN INCISION Make a paramedian incision 2.5 cm (not more) from the midline on the side where you expect to be working most, in the upper or lower abdomen, as required. If in doubt, centre it on his umbilicus, but carry the incision clear of it. If you expect to be working on a lateral structure, you will need good retraction to get adequate access, so make it at least 20 cm long.
Cut down to his rectus sheath, and then use the flat of the blade to clear 7 mm on either side, ready for closure later.
Divide his anterior rectus sheath, keeping well to its medial side. Above his umbilicus, where there are tendinous intersections, split it with a scalpel handle. The muscle medial to the split will be deprived of its nerve supply and atrophy, so don't split it more than than 2 cm from its medial edge. Put your two index fingers into the gap, and use them to split the rectus muscle in the length of the incision. Below his umbilicus split his rectus muscle or displace it laterally.
If necessary, tie his deep epigastric vessels before you divide his posterior rectus sheath. You probably won't see them because they lie laterally.
If his abdominal muscles bleed, clamp the bleeding vessels and tie them with catgut. Or, use pressure from a sponge. Or, transfix them with a figure of 8' catgut suture.
With his rectus muscle split, or out of the way, open his posterior rectus sheath and peritoneum as in Fig. 9.2, without injuring his gut! You can easily open it by mistake if: (1) it is obstructed, or (2) it has stuck to the a scar from a previous operation.
If you want to extend the incision, you can if necessary: (1) cut from his costal margin to his symphysis pubis, (2) extend the incision upwards between his xiphisternum and his costal cartilage, or (3) make a transverse cut in his left upper quadrant.
Fig. 9-4 A PARAMEDIAN INCISION. A, the site of the incision, which you can, if necessary, extend up to the inverted V' between the patient's xiphisternum and his costal cartilage, or down as far as his pubis. B, the way into his peritoneum. C, incising his anterior rectus sheath. D, incising his posterior rectus sheath after his rectus muscle has been split. E, the anatomy of the vessels to be tied. F, and G, incising his peritoneum. H, closing the muscles of his abdominal wall with a continuous monofilament single layer stitch. Alternatively, close the wound by Everett's method as in Section 9.8.
PFANNENSTEIL INCISION. See Section 23.15 and Fig. 23- 20.
ENTERING THE ABDOMEN Discovering what is wrong can be easy or very difficult. Be observant, learn to recognise what you see, and search thoroughly.
SMELL can tell you a lot. If a puff of gas greets you as you open his peritoneum, his gut has probably perforated. If there is an abnormal smell, it may be: acrid (a perforated peptic ulcer, or a typhoid perforation), faeculent (a ruptured caecum or sigmoid), the characteristic smell of E. coli (appendicitis with abscess formation or peritonitis), putrid (bacterioides or anaerobic streptococci), or urinary, as the result of an intraperitoneal rupture of his bladder.
LOOK FOR FLUID in his abdominal cavity, which may be: blood (an ectopic pregnancy or an injured liver, spleen, or mesentery); bile-tinged small gut contents (a perforated peptic or typhoid ulcer); a foul, turbid brown fluid (peritonitis from appendicitis); a watery, light-brown, odourless fluid (intestinal obstruction without strangulation); a watery, reddish-brown, offensive fluid (strangulation with incipient gangrene); or a pale straw-coloured fluid (ascites).
If there is any exudate, send it for culture, if you can.
If his peritoneum is fiery red with flakes of fibrinous exudate, he has peritonitis[md]see Section 6.2.
If there is bile-stained fluid in his paracolic gutter, he has probably perforated his gall bladder.
If he has an odourless greenish blood-stained effusion, he probably has pancreatitis (uncommon). Look behind his ileum at the peritoneum over his pancreas. Retroperitoneal oedema will help to confirm the diagnosis. Examine his omentum for flecks of fat necrosis.
If loops of his gut are distended, he has ileus, or his gut is obstructed. First find a loop of undistended gut. If there is one, then trace it proximally and you will find the obstruction. See Section 10.4.
If thickened oedematous omentum is adherent to something, it is a sign of acute inflammation, or strangulation (10.3), or abscess formation (6.3).
EXAMINE THE REST OF HIS ABDOMEN How extensively you should do this will vary. Limit your exploration to what is easily practicable if: (1) there is sepsis, or (2) you are operating for a known problem, or (3) your incision is a small one.
If there is infection, examine the infected area first. When you have dealt with it, consider whether you have done enough. Further exploration may spread the infection.
If there is carcinoma, start with the organs most distal to the diseased area, proceeding centripetally' towards the lesion.
If there is no obvious abnormality, search his abdomen in an orderly way. Examine his diaphragm and the upper surface of his liver, then examine his spleen, his stomach, his duodenum, and his intra-abdominal oesophagus. Examine his gall- bladder region. Then examine the whole of his small gut. Draw each loop out of the wound and then return it. Feel his major vessels. Feel his kidneys and look at his ureters. Examine the bladder, rectum, uterus, tubes, and ovaries. Finally look at his hernial orifices from inside. Don't forget to record your findings. Even negative ones can be most helpful later.
If you accidentally perforate a distended loop of gut, don't panic. Leave it there while someone gently clamps it with non-crushing clamps, and you surround the injured loop with packs to prevent the contents of his gut flooding into his peritoneal cavity. Have the sucker ready; repair the damage.
GET ADEQUATE EXPOSURE AND A GOOD LIGHT. You cannot do good work if loops of gut are always getting in the way, or if the light is bad, so adjust it as best you can. Make an adequate incision. If necessary extend it in one of the accepted directions. If you are working on a lateral organ through a midline incision, it will have to be a long one. Or, make a lateral T-shaped extension
Get good retraction. A self-retaining retractor will not be enough by itself. Use Deaver's retractor, or any large right-angled retractor, and make sure your assistant knows what you want him to do with it.
Get him into the best position You will never get adequate exposure in the pelvis unless his head is down in the Trendelenburg position. Similarly, if you are working on his upper abdomen (as when doing a vagotomy), tilt his head up a little. Extending his back by breaking the table or by putting a pillow under him will also help. If you want to draw his splenic flexure and small gut towards you, consider rolling him to the right, either by tilting the table or by using sandbags, or a wooden wedge under the mattress. If you are operating on his kidney, a kidney bridge or folded plastic-covered pillows will bring it forwards.
If loops of small gut (or anything else) get in your way, pack them away. This may save you much time, but don't forget to remove the packs afterwards! Anchor each pack by its tape or corner to a large haemostat hanging outside the abdomen.
MINIMIZE THE RISK OF SEPSIS. (1) If you have to open a hollow viscus, or an abscess, pack his abdominal cavity round it with packs or moist towels. Use clamps to prevent the contents of his gut escaping. (2) Handle an inflammatory mass carefully[md]don't let it burst and discharge pus everywhere. (3) Avoid any manipulation which might spread infection. (4) If an area does become contaminated, wash it out (6.2). (5) Insert drains when indicated (4.10).
BLEEDING can be difficult. You must know how to: (1) tie vessels in the depth of a wound (3.2), (2) tie them in continuity (3.2), (3) use curved and angled forceps, (4) secure temporary tape control over major vessels (55-4).
If a surface is merely oozing, consider applying haemostatic gauze (3.1).
If the bleeding is annoying, rather than brisk, you may be able to suck it away while you go on working.
If you have diathermy, consider applying it to the bleeding point with a fine-tipped dissecting forceps. You can do this with pin-point accuracy.
If bleeding becomes unmanageable, apply packs and pressure (3.1). You can even control bleeding from an avulsed renal artery like this. After 5 to 10 minutes, slowly remove the pack and clamp the bleeding point. If the vessel is a large one or deep, underrun it with a figure of 8' or a double mattress transfixion suture.
If there is a constant ooze during the operation: (1) the patient may have an excess of citrate, after the transfusion of many units of blood. This will not happen if you give him 10 ml of 10% calcium gluconate after every 4th (500 ml) unit of blood. (2) He may have DIC (disseminated intravascular coagulation), or some other clotting defect. If possible give him at least 2 units of fresh blood to replace clotting factors.
If you are absolutely desperate, as with bleeding from a ruptured uterus, try compressing the patient's aorta against her spine with your hand, until you have resuscitated her, and then tie her internal iliac arteries (3.5).
CAUTION ! (1) Don't stab blindly with a haemostat in a pool of blood! (2) Similarly, don't apply diathermy through a pool of blood[md]it won't work!
THE SPECIFIC CONDITIONS you might find when you do a laparotomy are described elsewhere[md]intestinal obstruction (10.3), peritonitis (6.2), intra-abdominal abscesses (6.3) etc.
THE SPECIMEN. If you have removed tissues from the patient and want to examine them, hand them to someone else and ask him to open them away from the patient, who will then not be contaminated by infection or malignancy.
To close his abdomen, go to Section 9.8. If you have operated for sepsis, delayed closure of his skin may be wiser.
DIFFICULTIES [s7]WITH A LAPAROTOMY If you CANNOT DO AN OPERATION THROUGH ONE INCISION, make another. Keep your original one open until you have finished[md]it may be useful!
If you want ACCESS TO A HUGE TUMOUR: (1) Start between his xiphisternum and his rib cage, and bring the incision outwards a little to become a standard upper rectus splitting paramedian incision. Continue horizontally just above his umbilicus for 5 cm. Then continue it down the other side of his lower abdomen to the brim of his pelvis as a muscle-splitting paramedian incision, as in B, Fig. 9-1. Or, (2) make a midline incision from top to bottom, skirting his umbilicus.
If you OPEN HIS PLEURA BY MISTAKE, there is a danger that his lung may collapse and cause marked hypoxaemia, not only because only one lung is being ventilated, but also because blood is passing through his collapsed lung unaltered.
If he is not intubated, stop operating to make it easier for the anaesthetist to pass a cuffed tracheal tube using suxamethonium (A 14.2). To do this you may have to move him. As soon as the tube has been inserted, close the hole in his pleura with a continuous multifilament suture. As you insert the last stitch ask the anaesthetist to blow up his lung so that it almost touches his pleura. At the end of the operation insert an intercostal water seal drain (65-5) and leave it in place for at least 48 hours. X-ray his chest, and if his lung is fully expanded, remove the drain, usually at 3 to 5 days.
If you are unable to intubate him, do the same. His lungs will usually expand postoperatively.
Fig. 9-6 SUTURING GUT. A, suturing gut with continuous Connell sutures, showing the principle of the loop on the mucosa' inverting the gut. Continuous Connell sutures like this are only used occasionally in the methods described here. Aa, gut anastomosed end-to-end with two layers of sutures: (1) an all coats' layer, (2) a layer of Lembert sutures through the serosa only.
B, the closed method of anastomosing gut end-to-end in Fig. 9-9 uses three Connell stitches. This is the first one on the antemesenteric border of the gut. C, the second Connell stitch, when the suture has reached the mesenteric border, and is about to turn round to close the anterior layer of the gut. D, the third and final Connell stitch closes the gut back at the antemesenteric border again.
E, the two layers of sutures: (1) the first continuous catgut all coats' layer and (2) the second or Lembert layer which can be interrupted or continuous; here it is continuous. F, a purse string suture for the appendix. G, Payr's crushing clamp, with firm, narrow blades. H, Lane's non-crushing clamp with springy, broad blades. I, correctly anastomosed gut. J, the gut has been cut obliquely in a way which reduces the blood supply to an area on the antemesenteric border of one loop. K, the gut has been partly deprived of its mesentery, and thus of its blood supply. L, the mesentery has been bunched together with a suture which occludes the vessels supplying the gut. M, gut which has been crushed by a crushing clamp has not been resected. N, the correct method; the gut is being held for suturing by a non-crushing clamp; crushed gut has been excised.
Resecting and anastomosing gut, end-to-end anastomoses
When you do a laparotomy it will often be because you need to resect and anastomose a patient's gut. This is one of the most critical procedures you will have to undertake, and if you are inexperienced, one which will give you much anxiety. It is one of the few surgical methods which you can usefully practise before you operate on a living human patient. So go to the butcher's, get some animal gut, and practise anastomosing that. The penalty for failure will be peritonitis or a fistula.
Gut is most often anastomosed end-to-end, but there will be occasions when you will have to do it end-to-side, or side-to- side. You may also have to anastomose a patient's stomach to his small gut in a gastroenterostomy.
Don't be worried by the complexity of the methods which follow. The really important points are to: (1) Make sure that you start with two nice viable pink bleeding ends. (2) Get their serosal surfaces together. If you do this, they will soon unite. If only the mucosal surfaces touch one another they are less likely to unite, and more often leak. (3) Close the gut in two layers. You have got to be much more neat and accurate if you only use one. Don't worry about mucosa pouting out after the first layer, it can easily do this at the mesenteric border. Everted mucosa leaks. So if it everts as dog ears', push these back when you do the second layer. (3) Do the suturing outside the abdominal cavity on a towel. Contamination will then be less likely and clamps less important. (4) Wash the gut with tetracycline solution after you have done the anastomosis.
If you follow the four points above you won't go far wrong. Now for some of the others: Any sutures which go right through the wall of the gut (and so might leak) are usually infolded by a second layer of sutures which go through serosa and muscle only[md]these are called Lembert sutures. So close gut in two layers. Put the first layer through all its coats[md]this is the all-coats' layer. Make the Lembert sutures of the second layer bring the serosa of one loop into contact with the serosa of the other loop. Only put them through the peritoneum, the muscle, and the submucosa (the strongest layer of the gut), and don't go through the mucosa into the lumen of either loop.
You will need to hold the gut with stay sutures or clamps while you work on it. It is also desirable to hold it shut so that its contents don't leak out. Clamps do this best but you can use a tape. There are two kinds of clamp: non-crushing ones and crushing ones.
Non-crushing clamps, such as Lane's or Kocher's have thin, wide, flexible blades, and a ratchet with several teeth, so that you can adjust the way you close them to the thickness of the gut. Use non-crushing clamps to hold gut without injuring it; hold them between your fingers and milk' the gut contents away from the area you are working on. Apply only as many clicks of the ratchet' as you need to stop the contents of the gut from escaping, and blood from flowing from the cut ends.
Crushing clamps have narrower, stiffer blades, a ratchet with fewer teeth, and sometimes interlocking ridges on the blades to grip the gut more firmly. Crushing clamps prevent leaking completely. Milk' the contents of the gut away from the area to be crushed, and then apply a crushing clamp with its jaws protruding well beyond the edge of the gut, because gut widens as you crush it. Close the jaws tightly. Crushed gut dies, so cut the crushed gut away with the clamp. As you do this, be sure there is a non-crushing clamp nearby to stop the contents of the gut spilling out. Crushing clamps are thus always used with non-crushing ones. You can use crushing clamps in pairs or in sets of four as in Fig. 9-9.
You can use what we describe here as the closed method' or you can use the open method'. The closed method is usually done with clamps, but it can if necessary be done without them. The open method is usually done without clamps, but it can be done with them. Both the descriptions here assume you are doing an end-to-end anastomosis.
The closed method' with clamps is shown in Fig. 9-9 and is the standard one, because it causes the least contamination of the peritoneal cavity. You have first to join the back of the patient's gut (as it lies in front of you) and then the front. The important places for leaks are where the back and the front parts of the anastomosis join one another, at the mesenteric and the antemesenteric borders of the gut. If serosa of one loop is to be in contact with serosa of the other loop at these critical points, the gut here must be inverted. The stitch which does this best is the Connell stitch. You can use Connell stitches all along the front of the gut (A, in Fig, 9-6), but this is not the easiest way of stitching gut. You should however make three Connell stitches where leaks are most likely. Make the first one at the antemesenteric border where you start the anastomosis (B, in this figure). Make the second one at the mesenteric border, as you turn over the edge of the gut from suturing its back to suturing its front (C). Make the third one at the antemesenteric border again when you are about to complete the first layer (D).
The principle of the Connell stitch is that the catgut comes out into the mucosa and then goes back into it again, and it comes out of the serosa and goes back into the serosa again. It makes a loop on the mucosa'. It is this loop which makes the mucosa invert.
The open method' without clamps is shown in Fig. 9- 10. The important feature about this is less that it is open without clamps, than that it uses a single layer of mattress sutures (a second Lembert layer is optional, and this method can, if appropriate, be done with clamps). The open method is indicated: (1) In infants and small children, because all clamps crush their delicate gut to some extent. (2) If the two ends of the gut are of widely differing size, as when you need to join large and small gut end-to-end. (3) When you don't have any clamps. (4) When you cannot get clamps on to the gut, as when joining large gut to rectum after a Hartmann's procedure (10.10). The open method does however increase the risk of contaminating the peritoneal cavity. Pick up the gut in stay sutures. Use interrupted mattress sutures for the posterior layer (A, in Fig. 9-10) and continuous ones which pick up the mucosa in a second bite for the anterior layer (B, in this figure). These pick up a tiny bite of mucosa only after going through the whole gut wall. The last two stitches cannot be made too neatly, and have usually to go through all layers.
Some surgeons don't like this method. It is really a single layer method, which is not so safe. Even if you add a second Lembert layer, you cannot cannot continue this across the mesenteric border. Some say it is more difficult.
Which parts of the gut can you safely anastomose to which and when? (1) You can also safely anastomose small gut to small gut, and small gut to stomach. (2) You can safely anastomose the ileum to the colon, because it has a good blood supply, few bacteria, and its diameter matches that of the colon. Both these anastomoses are safe with obstructed gut. Anastomosing large gut to large gut is more dangerous, because it has a poorer blood supply and many bacteria. You cannot safely anastomose large gut to large gut when it is obstructed, and instead you have to let its contents escape through an ostomy (see Sections 9.6 and 32.27). When large gut is to be anastomosed, it has to be carefully prepared first with enemas and antibiotics, and even then it is safer if it is protected by a proximal colostomy.
Some other points. If you are not happy that you have made a satisfactory anastomosis (no anastomosis is ever quite watertight'), you can bring up a loop of omentum and stitch this loosely over the place which you think will leak. This is optional, and is not even desirable if you think an anastomosis is sound; but there are certain occasions when it is essential[md]notably the repair of a perforated peptic ulcer, as in Fig. 11-2.
Interrupted sutures use more suture material and take longer, so use continuous ones where you can: (1) In an adult you can use continuous or interrupted sutures for either layer, but, if you use non-absorbable sutures in an infant, they must be interrupted, because continuous sutures will not grow with him, and will eventually constrict his gut. (2) If the cut edges of the gut are not perfectly healthy, the patient very ill, and the risk of peritonitis great, use interrupted non-absorbable Lembert sutures.
In the small gut use whatever suture material you find convenient for either layer. In the stomach use catgut on an atraumatic needle for the first layer[md]if you use a non- absorbable suture material for this layer, it may be the site of ulcers later. Use whatever you find most convenient for the second (Lembert) layer[md]catgut, silk, cotton, or monofilament. In the large gut there may be an advantage in using non- absorbable sutures for all layers.
FORCEPS, intestinal, non-crushing, flexible blades, Kocher's, Doyen's or Lane's, 75 mm, two only. Use these to hold the gut while you anastomose it. Non-crushing clamps have been designed to exert the right pressure without being covered with rubber tubes. If you fit them with rubber, they may crush too tightly.
CLAMP, Payr's, intestinal crushing, lever action, medium size, 110 mm, two preferably four only. These are the standard crushing clamps.
CLAMP, Payr, intestinal crushing, lever action, small size for pylorus, 60 mm, two only.
THE ENDS TO BE JOINED MUST BE NICE AND PINK MINIMIZE CONTAMINATION Fig. 9-7 SOME GUT METHODS. If the gut that you want to anastomose end-to-end is unequal in size (A), you can make a nick in the antemesenteric border of the smaller piece (B), so that it enlarges (C). D, and E, the mattress sutures used for the posterior layer of the open method (A, in Fig. 9-10). After Turnbull RB. From a publication by Messrs Ethicon, permission requested.
METHODS FOR GUT TEN IMPORTANT POINTS. (1) Do the anastomosis on a towel outside the abdomen. (2) Don't contaminate the patient's peritoneal cavity; if you do, wash it out with tetracycline solution (1 g in 1000 ml of saline, 6.2). Be safe and wash any anastomosis with tetracycline solution when you have completed it. (3) Pick up gut with your fingers or Dennis Browne or Babcock's forceps, don't damage it with other forceps. (4) Cut the mesentery square with the gut, and don't undermine it. (5) Don't apply clamps so as to leave the antemesenteric border longer than the mesenteric one, or the tip of the loop will necrose (J, in Fig. 9-6). (6) Don't anastomose gut from which you have removed the mesentery (K, in that figure). (7) Don't occlude blood vessels when you suture the mesentery (L). (8) Don't use a crushing clamp when you should use a non-crushing one. If you do, you will leave crushed gut in the body (M)[md]excise it (N). (9) Don't use diathermy close to the gut: you may injure it so that it becomes nonviable. (10) If, when you have completed the anastomosis, the gut is not viable (purplish'), resect its ends and start again!
THE CHOICE OF THE METHOD depends on the nature of the operation, your skill, and the equipment you have. Commonly, you will need to anastomose small gut end-to-end.
If the loops of gut are equal or only slightly unequal in size, you can use either method. If you use the closed one, apply the clamp on the smaller loop of gut obliquely, but without depriving a tongue of gut of its blood supply. Don't do what has been done in J, Fig. 9-6!
If the loops are very unequal in size (as when anastomosing small to large gut), you will have to use the open method of end-to-end anastomosis, and make a small cut in the antemesenteric border of the smaller loop, as in A, to C Fig. 9-7. Or, you can do an end-to-side or a side-to-side anastomosis.
Fig. 9-8 IS THE GUT VIABLE? A, it is viable if: (1) its surface is glistening, (2) its colour is pinkish, or only slightly blue, (3) it feels resilient like normal gut, (4) it contracts sluggishly (like a worm) when you pinch it, and (5) you can see pulsations in the vessels which run over the junction between it and its mesentery.
B, it is dead and not viable if: (1) it tends to dry out and its surface is no longer glistening, (2) it is greyish purple, or a dark purplish red (or even black), (3) it feels like blotting paper, (4) it does not contract when you pinch it, (5) the blood vessels over it are not pulsating or are filled with black clot.
C, if you are in doubt, remove the cause of the strangulation, apply a warm, moist pack to it, and wait 10 minutes. If it is viable, its colour will change from dusky to its normal pink.
IS HIS GUT VIABLE? [s7]TO RESECT, OR NOT TO RESECT? CAUTION ! For any method of anastomosis the gut must be viable, which also means that its blood supply must be good enough (see below).
Wait to decide if a patient's gut is viable or not until you have removed the cause[md]divided an obstructing band, or untwisted gut which has twisted on its mesentery. You can usually tell if gut is going to survive or not. Base your decision on several of these signs, not on one only.
Gut is viable if: (1) its surface is glistening, (2) its colour is pinkish, or only slightly blue, (3) it feels resilient like normal gut, (4) it contracts sluggishly (like a worm) when you pinch it, and (5) you can see pulsations in the vessels which run over the junction between it and its mesentery.
Gut is not viable if: (1) it tends to dry out and its surface is no longer glistening, (2) it is greyish purple, or a dark purplish red (or even black), (3) it feels like blotting paper, (4) it does not contract when you pinch it, (5) the blood vessels over it are not pulsating or are filled with black clot.
If you are in doubt, remove the cause of the strangulation, apply a warm, moist pack to it, and wait 10 minutes. If it is viable, its colour will change from dusky to its normal pink. If this happens it is alive, even if you cannot feel the pulsations of the mesenteric vessels. It may be alive if some areas remain purplish because of bruising. But if these areas are large, or do not improve in colour, consider all the discoloured gut nonviable.
If a piece of gut is obviously nonviable, resect it and do an end-to-end anastomosis.
If only part of the wall of the gut is nonviable, as with a Richter's hernia in Fig. 14-1, you may be able to invaginate it. If you are going to do this, the nonviable gut must: (1) not be perforated, (2) not extend over more than 30% of the circumference of the gut, (3) not extend to the mesenteric border, because suturing here may interfere with its blood supply, (4) be surrounded by a border of healthy gut. Use two layers of catgut to bring the serosal surfaces of the healthy margins together in the transverse axis, so as to invaginate the nonviable segment into the lumen of the gut where it can safely necrose (E, and F, 14-1). If it does not satisfy these criteria, resect it. One contributor considers that oversewing with Lembert sutures like this is more difficult and more dangerous than resecting the the damaged loop. If this is so, resect it.
If there is a completely encircling narrow band of greyish white necrosis, resect it and do an end-to-end anastomosis: it may turn into a stricture of the gut later (Garr[ac]e stricture).
If you release a loop of gut from a constriction ring, be especially careful. The loop of gut itself may be viable, but there may be a narrow band of necrosis at both the afferent and the efferent ends. It may slough at these narrow areas. Experts would resect the gut. But, if you are not expert at gut resection, oversewing the necrotic areas with Lembert sutures may be safer. If so, make a note of what you have found and done. A Garr[ac]e stricture may form, and the obstruction may recur.
IS THE BLOOD SUPPLY GOOD ENOUGH? If the mesenteric vessels of the gut you are going to anastomose are not pulsating, trim it back boldly until its edge bleeds with healthy red blood. If this does not happen immediately, try waiting a few minutes. If the flow is not pulsatile, it may become so if you wait a few minutes. Pick up the bleeding vessels with 4/0 chromic catgut, and don't rely on your anastomotic sutures to control bleeding.
PURSE STRING SUTURES A purse string suture is an invaginating suture around a circular opening, and is most often used to bury the stump of a patient's appendix.
Place a continuous Lembert suture through the serosa and muscle only, all round the appendix, as in F, Fig. 9-6. Tie the first hitch of a reef knot, pull the ends of the suture upwards, and push the stump of the appendix downwards. If necessary, ask your assistant to pull up the opposite side of the purse string as you do so. If you happen to penetrate all layers of the gut, reinforce the purse string with some more inverting sutures.
ENTEROTOMY An enterotomy is an opening in the gut. You may have to make one to make an ostomy (9.5), to inspect the gut to see where bleeding is coming from (11.3), or to remove Ascaris worms (10.6) or a foreign body (10.14).
Make an opening in the antemesenteric border of the gut and close it transversely in two layers as if you were anastomosing gut. In this way you will not narrow its lumen.
Fig. 9-9 END-TO-END ANASTOMOSIS BY THE CLOSED' METHOD. This method uses 4 crushing clamps. Clamps X' and Y' in Step B are optional, and it can be done without any clamps using stay sutures or tapes instead. The first pair of crushing clamps are removed with the loop of gut in Step E. The second pair are cut off in Step I. Non-crushing clamps are applied in Step B and remain on until Step N, although they are not shown after Step E. The critical parts of this anastomosis are the inverting Connell sutures in steps J, L, and N.
END-TO-END ANASTOMOSIS [s7]BY THE CLOSED' METHOD INDICATIONS. Anastomosing small gut, and large gut when there is not too much difference between the sizes of the lumen.
METHOD. This is the method in Figure 9-9. As shown it uses four crushing clamps and two non-crushing ones. You can readily leave out crushing clamps X' and Y' in B in this figure, and you can use no clamps at all.
Decide the length of gut you want to resect (A). Apply 4 crushing clamps in pairs close together at each end of the gut to be resected, and non-crushing ones on the gut to be anastomosed about 2 cm from the crushing ones (B).
If the mesentery is too thick for you to see the vessels clearly through it (as in the sigmoid colon, and the small gut mesentery in moderately fat patients, especially distally), divide the peritoneal layer nearest to you to outline the vessels (C).
Dissect the vessels one by one, pass a suture under each and tie it. Use 2/0 silk or chromic catgut on a mounted atraumatic needle (as shown in D), or an aneurysm needle, or a haemostat.
Divide the gut between each pair of crushing clamps (E).
(Note. From step F until step N each end of the gut is also held by a non-crushing clamp where this is convenient, although these are not always shown.)
Bring the crushing clamps together (F) and evert them (G).
Insert continuous Lembert sutures through the seromuscular coat of the posterior layer of the gut (the one which is furthest from you) starting at the antemesenteric border (H). Leave the ends long to act as stay sutures (I).
Cut the crushing clamps off by dividing the gut flush with them (I).
Start the all coats continuous inner layer at the antemesenteric border as a single all coats inverting Connell stitch (J). This is also shown in B, in Fig. 9-6. Use 2/0 chromic catgut. Continue as a simple over and over suture until you reach the mesenteric end K.
Insert the second all coats inverting Connell stitch on the mesenteric border (L) (also C, Fig. 9-6). Complete the anterior layer as simple over and over sutures (M) (or if you prefer as a continuous Connell suture A, Fig. 9-6). Insert the third Connell inverting stitch as you reach the antemesenteric end again (N) (also D, Fig. 9-6). Tie the two ends of the inner continuous suture together and cut them, leaving 5 mm ends. Now remove the non-crushing clamps.
Insert a continuous layer of Lembert sutures into the anterior seromuscular layer, starting at the mesenteric border and ending at the antemesenteric one. Tie each end to the free ends of the sutures that you have already inserted into the posterior layer and so complete the circle (O, and P). Test the patency of the lumen with your fingers (Q). Push some of the gut contents past the anastomosis to test for leaks. Close the defect in the mesentery with continuous 2/0 catgut or monofilament[md]taking great care not to occlude the vessels.
Fig. 9-10 THE END-TO-END ANASTOMOSIS OF UNEQUAL LOOPS OF GUT BY THE OPEN METHOD. Use this method if the ends of of the gut are of very unequal size, or if you don't have clamps. A, the interrupted mattress sutures of the posterior layer. B, the continuous sutures of the anterior layer, which take an extra bite of the mucosa. C, the gut occluded with an umbilical tape, the mesentery united and the ends of the gut held open with stay sutures. D, the first mattress sutures. E, more mattress sutures. F, a nick being made in the smaller loop of gut. G, insert some widely placed sutures to make sure that the circumferences of the two ends of the gut are exactly approximated. H, the final layer of Lembert sutures. After Turnbull RB. From a publication by Messrs Ethicon, permission requested.
END-TO-END ANASTOMOSIS [s7]BY THE OPEN METHOD INDICATIONS. (1) Anastomosing small gut to large gut. Or small gut to small gut when there is much difference between the sizes of the gut. (2) The absence of clamps. (3) Children.
METHOD. You can do this in two ways:
(1) You can follow Steps A to E and then J to R in Fig. 9-9, using stay sutures and tapes instead of clamps.
Or, (2) you can use the one-layer mattress suture method in Fig. 9-10. Pack off the peritoneal cavity. Prevent the gut contents from flooding into it by applying umbilical tapes around the gut. Cut the mesentery off square without undermining its cut ends. Apply stay sutures to open the ends of the gut.
To make the posterior layer use interrupted vertical through-and-through mattress sutures of 4/0 chromic catgut as in A, Fig. 9-10, and D, and E, Fig. 9-7.
To make the anterior layer, work from both sides towards the antemesenteric edge, and insert 4/0 chromic catgut sutures through all layers except the mucosa. Make a cut in the antemesenteric border of the smaller loop of gut. Don't trim the corners of the slit. Use continuous sutures which pick up the mucosa in a second bite for the anterior layer (B, Fig. 9-10). If the suture line is snug and inverted, stop at this stage. If not, complete the anastomosis with a final layer of Lembert 4/0 monofilament seromuscular sutures. You should be able to get most of the way round the gut, but you will not be able to suture its mesenteric border. This converts a one-layer method into a partial two-layer method.
End-to-side and side-to-side anastomoses
When one piece of gut is much larger than the other, an alternative to the open method of end-to-end anastomosis is to join them end-to-side. You can do this when you join the ileum to the colon after a hemicolectomy, or when one loop of small gut is much bigger than the other. Close off one end and make the anastomosis as close to this end as you can, so that there is no cul de sac' which might be colonized by bacteria. You can also join gut of differing diameters by joining it side-to-side.
TWO MORE ANASTOMOSES END-TO-SIDE ANASTOMOSIS INDICATIONS. Anastomosing small gut to large gut.
METHOD. Mobilize the patient's large gut for 5 or 10 cm, or more if it is very large. Apply a crushing clamp to the end, and cut it off flush. Push away the contents of the distal gut, and apply a non-crushing clamp to it (A, in Fig. 9-11).
Using a straight or curved needle, close the end of the gut with continuous atraumatic sutures working from side-to-side from one end to the other (B, and C). When you have got to the other end, pull the suture tight and remove the crushing clamps. Cut away the crushed tissue. Work back to the end where you started, this time making over and over sutures (D, and E). Tie the ends of the suture and cut them off 5 mm from the knot (F).
Cover the closed end of the gut with a layer of inverting Lembert sutures through the seromuscular coat using 2/0 silk or chromic catgut (G).
Push the contents of his large gut further down and move the non-crushing clamp 6 cm from the end (H). His small gut should have a non-crushing clamp applied 5 cm from its end. Bring it close to his large gut, and insert stay sutures through the seromuscular layers only (I). Complete the layer of interrupted seromuscular sutures (J).
Open his large gut, if possible along a taenia, so as to make a stoma equal in size to his small gut (K).
Start the inner all coats layer with a Connell inverting stitch (L). Continue this as an over-and-over suture to the other end, and use another Connell inverting stitch for that end (M). Return using an over-and-over suture for the anterior layer (N). When you reach the end close it with a third Connell inverting stitch (O). Tie the two ends of the continuous all coats suture together and leave the ends 5 mm long.
Insert a layer of interrupted inverting seromuscular Lembert sutures (P, and Q). Test the patency of the lumen[md]it should admit two fingers (R). Repair the defect in the mesentery with 2/0 catgut.
Fig. 9-11 END-TO-SIDE ANASTOMOSIS. A, to H, closing the blind end of the gut. E, to G, inverting the previous layer of sutures. H, moving the non-crushing clamp back. I, to K, the posterior Lembert layer of the anastomosis. L, and M, the posterior all- coats layer. N, and O, the anterior all-coats layer. P, and Q, the anterior Lembert layer. R, testing patency.
SIDE-TO-SIDE ANASTOMOSIS INDICATIONS. Anastomosis when the gut is of very different diameter and end to end or end to side anastomosis is difficult, as may happen if it is obstructed: (1) In the new- born when the distal gut is small, because it has never contained anything but meconium. (2) In older patients when end-to-end anastomosis is difficult because of differences in diameter. (3) When gut is difficult to mobilize because of adhesions, as sometimes when anastomosing the ileum to the colon.
METHOD. If gut has to be resected, first close the ends of both loops of the gut to be anastomosed, as for the larger end of an end-to-side anastomosis described above (A, to G, Fig. 9- 11). If there is no gut to be resected, leave the ends in continuity.
Expel as much of the contents of both loops as you can, and apply non-crushing clamps about 6 cm from the ends of each. Insert a layer of interrupted Lembert sutures through the seromuscular coats of both of them, starting with stay sutures at each end about 1 cm from the line of your proposed incision (A, in Fig. 9-12).
Incise both pieces of gut for about 3 cm, in the line of a taenia in the case of the colon (B). Starting with a Connell inverting stitch (C), use 2/0 catgut to join the posterior cut edges of the gut with an all coats continuous over-and-over suture (D). When you reach the other end make another Connell inverting stitch. Then continue the over-and-over continuous suture along the anterior layer of the anastomosis. Finally, complete it with another Connell inverting stitch (E) and tie the ends of the catgut together, leaving 5 mm cut ends.
Insert an anterior layer of 2/0 silk or catgut Lembert seromuscular sutures (F). Test the lumen of the stoma with your fingers (G) and move the gut contents over the anastomosis to check for leaks.
Fig. 9-12 A SIDE-TO-SIDE ANASTOMOSIS is useful for doing a bypass without resecting gut. A, if, as in this figure, gut has been resected, close the ends of the two pieces of gut as in the previous figure. If, as is usually the case, and you are merely doing a bypass operation, no gut has been resected, leave the ends in continuity. Hold them with stay sutures and join them with the Lembert sutures that will form the posterior layer of the anastomosis. B, open both pieces of gut. C, start the posterior all-coats layer with a Connell stitch. D, the posterior all coats layer has reached the other end, so now insert another Connell sitch. E, the third and final Connell stitch. F, insert the anterior Lembert layer. G, test the stoma for patency. Fig. 9-13 IF YOU CANNOT ANASTOMOSE GUT, for example in a typhoid perforation, bring the gangrenous segment (A) out through a separate incision (B), cut it off so as to make an ileostomy (C), and suture all coats of the patient's gut to the skin of his abdominal wall with interrupted sutures. Refer him quickly, because there will be much fluid and electrolyte loss, which you must replace. D, he may have several stomas. F, nurse him like this. E, and F, after the late Ian Hulme Moir.
Stomata and bypasses for large gut obstruction
The gut is a tube from the mouth to the anus which can become obstructed in various places. One way of overcoming such an obstruction is to make an opening or stoma or ostomy' above or below it, from the lumen of the gut out to the abdominal wall. In the upper part of the gut the purpose of an ostomy (a gastrostomy, or a jejunostomy) is usually to let food and fluid in; in the lower part it is to let the contents of the gut out (an ileostomy, a caecostomy or a colostomy).
An ostomy is seldom necessary in the small gut, because it contains so few bacteria that you can usually resect the obstruction, and anastomose its cut ends quite safely. Ostomies of the small gut cause large losses of water and electrolytes, so try to avoid them if you can. But you cannot so easily anastomose the large gut, which is not only full of dangerous bacteria, but also has a much poorer blood supply, so that anastomoses more easily break down and leak. The standard way to operate safely on the large gut is to wash it out and then to sterilize' it with a preoperative course of antibiotics, neither of which are possible in an emergency. So, in an emergency, you have to bring the cut ends of the large gut out to the surface as a colostomy, and close them later. There are two main ways of doing this: (1) You can bring a loop of gut to the surface and make an ostomy at its apex, without resecting any gut. Or, you can bring most of the loop out of the abdominal wall, close it and then resect the loop. This is called exteriorization. If you are not skilled, it is useful way of resecting gangrenous or injured gut, and making an ostomy without soiling the abdominal cavity.
Types of ostomy There are several types of ostomy for the large gut, and three standard places in which to make them. First the types. A loop colostomy is the most useful of these. In many cultures a patient would rather die than have any of them. So you may have to do some firm persuasion. Fortunately, ostomies are usually only needed temporarily. You can make any of these:
(1) A loop colostomy brings a loop of gut out of the abdomen over a short length of rubber tube, or a glass rod. This is the easiest ostomy to make and close extraperitoneally, and is suitable for most purposes.
(2) A double-barrelled colostomy, is a loop colostomy modified by stitching the last few centimetres of its limbs together inside the abdomen, so that they resemble a double-barrelled shotgun. The spur (wall) between the two loops is later crushed to make the colostomy easier to close with the special crushing clamp in G, Fig. 9-19. If you are not going to close a colostomy by crushing the spur, there is no point in double-barrelling it.
The advantage of both a loop and a double-barrelled colostomy is that you can close them extraperitoneally.
(3) A spectacles colostomy' has limbs that are separated by a small bridge of skin, as in Fig. 9-17. It is useful: (a) if a patient needs a colostomy for a long time, and (b) during the repair of a rectovaginal or vesicovaginal fistula, when work on the rectum and bladder has to be completed before the fistula can be closed. Because the loops of a spectacles colostomy are separated, it has to be closed intraperitoneally with a full anastomosis.
(4) An end (terminal) colostomy forms the end' of the gut after excision of the rectum, or in Hartmann's operation (see below).
(5) A mucus fistula (colostomy). A colostomy normally has two openings. The proximal one discharges faeces, and the distal one only mucus. This is the term which is sometimes given to the distal opening.
If you are making a colostomy low in the sigmoid colon, the distal loop may not be long enough to reach the surface as a mucus colostomy, so you have to close it and drop it back into the abdomen[md]this is Hartmann's operation (G, in Fig. 9-14). If necessary, you can drop a blind loop back into the abdomen anywhere; it will fill with mucus and discharge through the anus.
Some kinds of ostomy defunction' the colon better than others. This means that they are better at preventing faeces from entering the distal limb. This may be useful, for example, in protecting a wound in the rectum which you have just sutured. There are several degrees of defunctioning. It is most effective when the two ends of the gut are brought out through separate stab wounds, with the distal one above the proximal one. A spectacles colostomy' (9-17) is the next best. Neither a loop, nor a double barrelled colostomy, defunction completely, and a caecostomy is even less effective. Fortunately, a high degree of defunctioning is seldom important.
Fig. 9-14 OSTOMIES. A, exteriorization; the gut outside the abdominal wall is later resected to produce a colostomy. B, and C, stages in a loop colostomy. D, a double-barrelled colostomy. E, the ends of a colostomy come out of the same wound. F, they come out of different wounds. G, Hartmann's procedure, in which the distal end of the sigmoid colon is dropped back into the abdomen. H, an ostomy in the transverse colon. I, a caecostomy. J, a caecostomy with a large catheter inserted. K, an ostomy in the sigmoid colon. L, if the small gut is gangrenous, you can excise it and anastomose its ends, you cannot do this safely in an emergency with the large gut, because you do not have time to prepare it first. The sites for ostomies are shown in Fig. 9-14. There are three common places to make them: (1) In the caecum in the right iliac fossa (a caecostomy). (2) In the right side of the transverse colon in the right epigastrium. (3) In the sigmoid colon in the left iliac fossa.
A caecostomy can be made by placing a tube in the caecum and letting the liquid faeces drain. This is easier than doing a transverse colostomy, but: (1) The risks of soiling the peritoneum are greater. (2) A caecostomy often does not work well, and needs much washing out, so it is difficult to manage postoperatively. (3) It diverts little of the faecal stream. But, provided the tube is not too small, it may do this adequately. (4) It can only be temporary. A caecostomy is useful if a patient is desperately ill, and you can, if necessary, do one under local anaesthesia without exploring his abdomen. You will find a caecostomy useful if he has: (a) a caecal injury, or (b) a more distal obstruction, but is too ill for a colostomy.
A transverse colostomy can be made as a loop, or double barrelled, or as a spectacles colostomy. Always make it in the right side of the transverse colon. This should not be difficult unless the colon is very distended, or the mesocolon is short. Use a transverse colostomy as a preliminary to resection of the large gut for a left sided obstruction for carcinoma (32.27), for anal atresia (28.6), and for an injury (66.14).
A sigmoid colostomy is an alternative to a transverse colostomy for obstruction in the rectum or sigmoid colon, such as a sigmoid volvulus. Here again you can make a loop, or double-barrel it.
Closing ostomies can be more difficult than making them. A caecostomy will close by itself, but a transverse or a sigmoid colostomy will have to be carefully closed, unless the patient is to have his colostomy permanently. If you cannot refer him to have it closed, you will have to close it yourself. If possible, try to do this extraperitoneally, so that you avoid the risk of contaminating his peritoneal cavity. You can usually free the ends of a loop colostomy (9-15), or a double-barrelled colostomy (9-19), and sew them together without entering his peritoneal cavity. The ends of the loop may be partly united already, so that you have only to complete the rest of the anastomosis. If you cannot close a colostomy extraperitoneally, you will have to lift out the two loops of gut and close it intraperitoneally as in Fig. 9-18.
There is another way of closing a double-barrelled colostomy extraperitoneally, which is to slowly crush the spur between the two loops of the barrel with a special clamp, as in Fig. 9-19. This makes the barrels join one another, and makes the colostomy easier to close. Some surgeons like this method and others don't. It has the disadvantage of needing a special clamp, although you can use a large haemostat, as described later. Closing Hartmann's operation is much more difficult; if you have to do it, it is decribed in Section 10.10a.
Bypasses. The ostomies above all open a patient's gut to the outside. You can also relieve his obstruction by connecting one part of his gut to another with a bypass. It is often anatomcally difficult and it can be surgically dangerous to bypass one part of his large gut to another, but you can bypass his small gut to his small gut, or his small gut to his large gut. You can: (1) Bypass one part of his small gut to another, when it is obstructed and bound down by septic (10.7) or tuberculous (29-8) adhesions, which are difficult to free. This is an entero-enterostomy, usually an ileo-ileostomy. (2) You can bypass his small gut into to his large gut, by anastomosing his terminal ileum to his transverse colon, and closing the free end of his ileum, or leaving it open. This leaves the end of his ileum and his ascending colon as a blind loop. It is useful in amoebiasis (31.11) and carcinoma (32.27). Anastomosing his ileum to his transverse colon is more difficult than doing a caecostomy to relieve his obstruction, but is easier than removing his right colon (right hemicolectomy, 66-20). (3) You can bypass his ileum into his descending colon or rectum. This is major surgery: it will give him diarrhoea and most surgeons prefer a colostomy (32.27). (4) You can bypass his stomach into his small gut when his pylorus is obstructed (11.3).
Methods for ostomies
There are some important general principles: (1) Always try to bring an ostomy out through a separate smaller incision, and not through a laparotomy incision, unless you have to, because the wound is much more likely to become infected, and perhaps burst. (2) With all colostomies do Lord's procedure (maximal anal dilatation 22.5) before you send the patient back to the ward. This will temporarily paralyse his external sphincter, and allow his distal colon to drain more easily.
Sigmoid volvulus is the commonest cause of obstruction of the large gut in much of the developing world, so it is described elsewhere (10.10), and with it the detailed method for doing a sigmoid colostomy. Here are details of the other methods.
CLAMP, enterostomy, crushing, Lloyd Davies parallel action to take apart, one only. This is for crushing the spur of a double-barrelled colostomy.
OSTOMIES In most patients you will need to follow the general methods for intestinal obstruction in Section 10.3.
CAECOSTOMY [s7]UNDER LOCAL ANAESTHESIA INDICATIONS. (1) Penetrating injuries of the caecum. (2) An obstruction proximal to the mid transverse colon, if you feel unable to do a right hemicolectomy. (3) Obstruction anywhere in the colon, if the patient is too ill for a colostomy. (3) A minimally skilled operator faced with any large gut obstruction.
X-RAYS. Before you start, make sure exactly where the patient's caecum is. Look for its gas shadow on the X-ray. It can be suprisingly high. Percuss his abdomen to make sure.
EQUIPMENT. A large (30 Ch) Malecot or, less satisfactorily, a large de Pezzer catheter with the top of its bell cut off.
ANAESTHESIA. General or local anaesthesia (A 6.7).
METHOD. Study Figure 66-18. Then, with the greatest possible care, make a small gridiron incision at McBurney's point (12-1) well laterally over his dilated caecum[md]you can easily nick or burst it. Put packs round the wound inside his abdomen to minimize the consequences of spillage. Have suction instantly available.
Partly deflate his caecum by needle aspiration (10-9), or by decompression (after placing a purse string suture round it), so as to take the tension off it. As soon as you have done this, its walls will become thicker and more vascular.
If his caecum is mobile enough to deliver out of his abdomen, gently bring it out, assisted by Dennis Browne forceps if necessary. In practice this is seldom possible. If you succeed, drain it, and then apply the anchoring sutures described below.
If it is not mobile enough, insert several 3/0 atraumatic chromic catgut sutures from the cut edges of his peritoneum to a 6 cm ring on his caecum. Pick up its seromuscular layer only. Don't penetrate its mucosa. Leave the sutures long, hold them in haemostats and don't tie them yet. Make another 4 cm purse string circle inside this.
With suction immediately handy and the surrounding area carefully packed off, make a small nick in the centre of the purse string. Flatten the end of the catheter in a haemostat. Using a screwing movement, quickly push the haemostat and catheter through the nick in the centre of the purse string. Open the jaws of the haemostat to release the catheter, remove the haemostat, and quickly tighten the purse string to secure the catheter in place.
CAUTION ! Make sure the catheter can drain off to the side, so that it does not flood his abdomen.
Close the muscle layers of his abdominal wall with interrupted catgut, monofilament, or steel wire, but leave his skin unsutured. His wound is sure to become infected, and this will minimize it. Suture the catheter to his skin to prevent it being pulled out. Clamp it and block it with a spigot, until he returns to the ward. Then connect it to a bag or bottle. Flush it out with one or two litres of saline, which need not be sterile, at least twice a day.
DIFFICULTIES [s7]WITH A CAECOSTOMY If his CAECUM BURSTS with a puff of gas as you open it, suck vigorously. This will not be a major disaster if you have previously sutured the cut edges of his peritoneum to his caecum, and so isolated his peritoneal cavity. Deliver his burst caecum, and extend the incision if necessary. Apply a soft clamp and repair the perforation, invaginating it as you do so. Then do a standard caecostomy away from the site of the perforation. Alternatively, exteriorize his caecum. If necessary, you can sew the caecostomy tube into the tear in his burst caecum, provided it is not necrotic or gangrenous.
If, when you open his peritoneum, you find that his CAECUM IS GANGRENOUS but has not yet perforated, exteriorize it. Make a bigger wound and deliver his caecum through it. Resect it. You now have two choices; (1) You can do an end-to-side anastomosis of his ileum to his terminal colon (9-11). Or, (2) you can close his colon, exteriorize the gangrenous area, do an ileostomy and then close this 3 weeks later. Meanwhile, he will lose much fluid and many electrolytes.
If you DON'T HAVE A SUITABLE CATHETER, you can stitch the wall of his caecum to his parietal peritoneum before you open his caecum. Then apply a colostomy bag over the opening. The difficulty with this is that it tends to close spontaneously.
Fig. 9-15 A LOOP COLOSTOMY IN THE TRANSVERSE OR SIGMOID COLON. A, make these incisions for a transverse or a sigmoid colostomy. B, incise the rectus muscle for a transverse colostomy. C, incise the greater omentum and bring a loop of transverse colon through it. D, incise the mesentery. E, bring the transverse colon through the greater omentum. F, push a piece of tube or a glass rod through the hole, and suture the colon to the peritoneum. G, close the wound. H, open the colon and suture it to the edges of the skin wound. I, the completed colostomy. J, after healing of the wound. After Goligher JC, The Surgery of the Anus, Rectum and Colon', Figs 347 to 361. Bailli[gr]ere Tindall, with kind permission.
TRANSVERSE COLOSTOMY INDICATIONS. (1) Obstruction distal to the middle of a patient's transverse colon. (2) A penetrating injury of his transverse colon. (3) Gangrene of part of his transverse colon due to strangulation or interference with its blood supply. (4) A rectovaginal fistula prior to repair. (5) Protecting an anastomosis for sigmoid volvulus after resection.
A transverse colostomy is not difficult, and is better than a caecostomy. There are 3 types: (1) A plain loop. (2) A double- barrel colostomy. (3) A spectacles colostomy' as in Fig. 9-17.
METHOD. Make a right (or left) paramedian incision centered on his umbilicus. Open his peritoneum with the greatest care, as for any gut obstruction (9-2).
Try to find his transverse colon without allowing loops of his small gut to protrude from his wound. They will probably bulge into the wound, covered by omentum.
Lift his omentum upwards and forwards, so that you can see his transverse colon. Is it very distended? If it is not distended, his large gut is probably not obstructed and you will have to look for some other pathology. If it is very distended, you may need to deflate it first (10-9). Is it mobile enough to lift forward to skin level? If he is very obese, this may be difficult.
Make a 4 cm separate transverse skin incision above and to the right of the laparotomy incision, as in A Fig. 9-15. Divide his anterior rectus sheath in the same line as his skin. Cut his rectus muscle transversely. Your index and middle finger should be able to lie comfortably in the wound, but should not allow another finger to enter it.
CAUTION ! (1) Make the incision well to the right. (2) It must be high enough to avoid his umbilicus, and not so high that his transverse colon cannot reach it. (3) Make it just large enough to take the loop comfortably. (4) Make sure you have got his transverse colon and not his stomach or his sigmoid colon! The transverse colon has taenae (unlike the stomach), and is attached by a short omentum to the greater curvature of the stomach.
Choose an area of his transverse colon to the right of the midline. Trim off the omentum attached to 7 to 10 cm of its anterior surface so as to make a gap in it (C, Fig. 9-15, B, Fig. 9-19). Try to avoid tying any small vessels that may be present. Deliver a loop of his transverse colon through this gap.
Make a small window in his transverse mesocolon next to the mesenteric border of his colon (D, Fig. 9-15, C in Fig. 9-19). Do this by pushing a large blunt haemostat through it close to the wall of his gut, while you open and close its jaws. Avoid injuring the branches of his middle colic artery as you do so.
Pass a rubber catheter through the window you have made, and grasp both its ends with a haemostat (D, Fig. 9-19). Test the colon for mobility again. If it is very tense and distended, decompress it.
If you want to double-barrel it, insert a few interrupted catgut sutures between its loops, biting only its seromuscular coat as in D, Fig. 9-19.
CAUTION ! You must be able to deliver the loop of colon you have isolated through the transverse incision comfortably.
Push a second haemostat through the smaller transverse incision that is to be the site of the colostomy, and grasp the catheter you have placed round his colon. Release the first haemostat, and by pulling with one hand and pushing with the other, withdraw the loop of colon, so that it comes out through the colostomy incision and rests on his abdominal wall.
If the wound is loose enough to let you insert a finger alongside the loop of colon, there will be no risk of the lumen occluding, and the colostomy should function satisfactorily. If his colon is not loose enough, extend the incision.
Close his abdomen so as to withstand a high intra-abdominal tension, as in Section 9.8.
Pass a short piece of thick rubber tube, or a short glass rod attached to a piece of rubber tube, through the window occupied by the catheter(F, Fig. 9-15), and keep it there with two stitches anchored to his skin. Pass a few interrupted sutures between the fascia of his abdominal wall and the seromuscular layer of his gut, and between his skin and the free margin of his gut.
CAUTION ! Before you place these sutures, make sure his colon is not twisted, and that it runs transversely, as a transverse colon should.
Open his colostomy immediately. If you delay, his obstruction is not relieved. Apply a substantial dressing to the laparotomy wound. Make a 3 cm incision (as in E, Fig. 9-19) through both coats of his colon across its axis (in line with the rubber tube), or better, longitudinally along a taenia (G, and H, Fig. 9-15). It will open to form two stomata (I, Fig. 9-15). You will have to close the opening transversely to avoid obstruction: opening it longitudinally ensures a wider lumen. Suture his skin to his mucosa, as in H and I, Fig. 9-15. Push a finger down the afferent loop to make sure that it is patent[md]a gush of gas and faeces is an encouraging sign. If possible, apply a commercial colostomy bag. If not, improvise one as in Fig. 9-16.
SIGMOID COLOSTOMY INDICATIONS. (1) Wounds of the rectum. (2) Chronic obstructive rectal lesions including carcinoma. (3) Following resection for sigmoid volvulus.
CONTRAINDICATIONS. Situations in which a sigmoid colostomy wound would interfere with subsequent operations, for example the repair of a rectovaginal fistula.
METHOD. This is described under volvulus of the sigmoid colon as part of Hartmann's operation in Section 10.10 and Fig. 10-16. It also closely resembles a transverse colostomy. You can double-barrel' and spectacle' it as with a transverse colostomy, as described above, or leave a blind distal end.
Draw a line from the patient's umbilicus to his left iliac spine (A, in Fig. 9-19). Site the mid point of the incision at the junction of the medial two-thirds and the lateral one third. This is the same as McBurney's point but is in the left iliac fossa. Site the incision carefully. Choose a site for the stoma in the upper part of the mobile loop of the sigmoid colon, to prevent the colostomy prolapsing later.
Fig. 9-16 IF YOU DON'T HAVE A COLOSTOMY BAG, you can make one from an ordinary plastic bag, a tin, a piece of rubber, such as that from the inner tube of a car tyre, and a piece of string. The tin should be a small one and should fit comfortably over the patient's colostomy. A small Carnation milk' tin works well, provided it has no sharp edges. Make holes for the string in the side of the tin, and make sure it has no sharp edges. You can also use a pessary ring to hold the bag. If you are using disposable bags be sure to give the patient enough. A washable non-disposable bag may be more practical. He needs at least two. Make sure that he or his relatives know how to wash and use them. D, E, and F, an ostomy appliance made from a coconut and a plastic bag. A, B, and C, kindly contributed by John Tarpley.
END (TERMINAL) COLOSTOMY INDICATIONS. (1) As part of Hartmann's procedure when this is done for sigmoid volvulus or for any other reason. (2) Severe damage to the pelvirectal colon complicating surgery for PID (6.6). (3) A permanent colostomy, as after resection of a low carcinoma of the rectum.
The disadvantage with the method which follows is that it leaves a lateral space through which gut can herniate internally. The alternative, which is to lead the sigmoid colon through an extraperitoneal tunnel round the left paracolic gutter, is too difficult to be described here.
METHOD. Make an appropriate incision in the patient's abdominal wall, as in A, Fig. 9-15. Insert a crushing clamp through it and draw out the end of his gut. Before you close his abdomen, put in a few catgut sutures between the seromuscular coat of his gut, and the peritoneum of his abdominal wall. Place them so that there will be 1.5 cm of healthy gut protruding beyond the skin, then close his abdomen.
To open the colostomy, cut off the crushing clamp with a sharp scalpel. Control bleeding. Suture mucosa to skin all round with interrupted 2/0 or 3/0 monofilament.
Ideally, use the method in F, and G, Fig. 9-17. Use stitches which take a bite of: (1) his anterior rectus sheath without going through his skin, (2) the seromuscular coat of his gut about 8 mm proximal to its tip, (3) the mucosa and seromuscular coat of the tip of his gut. When you eventually tighten these sutures, you will find his colostomy will evert itself beautifully.
BYPASSES AN ILEO-TRANSVERSE COLOSTOMY takes the end of his ileum about 15 cm from his ileocaecal valve, and anastomoses it to his transverse colon, leaving the stump of his ileum, his caecum and his ascending colon in place. Use it to provide temporary relief for obstruction of his caecum or ascending colon, by ileocaecal tuberculosis (29.5) or carcinoma.
Make an end-to-side anastomosis, as in Section 9.4, Fig. 9- 11. Use the second part of the method of end-to-side anastomosis in Fig. 66-20. Close the stump of his ileum with an all-coats layer, and then invert this with Lembert sutures (one contributor leaes the stump open, it will not leak into the peritoneal cavity). Leave his right colon and the stump of his ileum in place to be joined up later.
AN ENTERO-ENTEROSTOMY. Make a side-to-side anastomosis as in Fig 9-12. This figure shows the ends of the gut resected: you usually need to leave them in continuity. Make it between adjacent loops of his small gut (for obstruction of his small gut by adhesions or tuberculous peritonitis), or between his small gut and his large gut (G, Fig. 32-15b) for obstruction of his ascending colon, usually by ileocaecal tuberculosis or carcinoma.
Fig. 9-17 MORE METHODS FOR OSTOMIES. A, the site of the incision for a spectacles colostomy. B, the spectacles incision. Remove the skin inside each loop. C, turning back the flap. D, the transverse colon exteriorized and clamped with two crushing clamps. E, the completed colostomy. F, and G, a secure method of suturing a patient's colon to his abdominal wall.
SPECTACLES COLOSTOMY INDICATIONS. A moderately defunctioning colostomy, as in preparing a child with an imperforate anus for definitive surgery later.
METHOD. Site the spectacles colostomy in his right hypochondrium, as in A, Fig. 9-17. Make a spectacles-shaped incision (B), and remove the skin inside each loop. Turn back the flap (C). Exteriorize and clamp the transverse colon with two crushing clamps (D), to make the colostomy (E).
Fig. 9-18 CLOSING A LOOP COLOSTOMY INTRAPERITONEALLY. Only do this if you cannot close it extraperitoneally, as in the next figure, which is safer. A, insert traction sutures. B, raise an ellipse of skin round the colostomy. C, dissect the ellipse of skin free from the rectus sheath. D, free the colostomy loop. E, excise a cuff of skin and evert the gut edges. F, the proximal gut edge is everted, the distal gut edge is still inverted. G, and H, closing the colostomy with Connell loop-on-mucosa stitches. I, inserting a second layer of seromuscular Lembert sutures. J, closing the muscles of the abdominal wall in one layer. After Maingot R, The Management of Abdominal Operations', Figs. 396 to 404. HK Lewis, with kind permission.
CLOSING A COLOSTOMY INTRAPERITONEALLY If you cannot refer him, do this 4 to 6 weeks later, when his wound is healthy and he has recovered from his original operation.
CAUTION ! (1) He will be hoping for this as soon as possible. Don't let him persuade you to do it too early. (2) It is not an easy operation, so refer him if you can.
Wash out his gut proximally, and distally through his rectum. Repeat this daily for 2 or 3 days before the operation. Some surgeons give him magnesium sulphate to help empty his proximal gut and to make sure that the next faeces he passes will be soft. Give him neomycin 500 mg 6-hourly for 2 days, then give him oral perioperative chloramphenicol and rectal metronidazole (2.9).
To minimize bleeding infiltrate the skin and subcutaneous tissues around his colostomy with a local anaesthetic solution containing adrenalin 1:200,000 (A 5.4). Wait to allow the anaesthetic to act. Or, use general anaesthesia. The infiltration is valuable in demonstrating tissue planes.
Insert traction sutures round the colostomy (A, in Fig. 9- 18). Make an elliptical incision round it (B). Use a fine knife and sharp scissors to dissect it free from the surrounding skin and fascia, and from the muscle of his abdominal wall (C). Keep a finger in the lumen to tell you when you are getting dangerously close to it.
Raise the ellipse of skin from his abdominal wall (D). Using sharp dissection, clean the sheath of his rectus muscle until you reach the edge of the opening through which his gut is passing.
If, at this stage you think you can unite the two loops of his gut extraperitoneally, do so (see below).
If this is difficult, you will have to enter his peritoneal cavity. Free the parietal peritoneum round the circumference of the opening. Divide any adhesions that may be present. Draw his colon out of the incision, and place packs over the wound. Trim away the everted edges of his gut (E). Close it transversely with Connell stitches (G, and H; see also A, Fig. 9-6). Start by placing two atraumatic sutures through all the coats of the gut where his proximal and distal colon meet. Tie the knot in the lumen, and work from each side.
Check, by pinching with your fingers, that, when you cut off the skin remnants and closed the colostomy, you left plenty of room for faeces to go through.
If there is enough room for his faeces to go through, add a second layer of interrupted Lembert inverting sutures through the seromuscular layer (I), and tuck it into his abdomen.
If there is not enough room, resect the colostomy and do a new end-to-end anastomosis.
Close his abdominal wall with interrupted sutures. Now do a Lord's procedure (maximal anal dilatation) before he goes back to the ward.
Fig. 9-19 A DOUBLE-BARRELLED COLOSTOMY. MAKING IT AND CLOSING IT EXTRAPERITONEALLY. A, the incisions. B, the site in patient's mesentery through which to pass the loop of bowel. C, the site in his mesocolon through which to pass the rubber tube. D, the loop double-barrelled and brought out through the transverse colostomy incision using a rubber tube. E, opening his colostomy (in this case transversely), and anchoring it in place with a short rubber tube. F, skin-to-mucosa sutures have been inserted all round. G, applying the crushing clamp when his colostomy is ready for closure. H, the two stomas are now one. After checking that loops have united in the depths of the wound, infiltrate around the colostomy and use the skin incision shown. I, excising the skin. J, the gut sutured and about to be returned to his abdomen with a drain. K, a cross-section of the finished colostomy.
CLOSING A COLOSTOMY EXTRAPERITONEALLY This mostly applies to a loop colostomy and a double- barrelled colostomy with a spur that can be crushed. The description that follows is for the double-barrelled colostomy in Fig. 9-19, but you can do it with the loop colostomy in Fig. 9- 15.
As soon as the patient no longer needs his colostomy, crush the spur, as in G, Fig. 9-19. When you are ready, put one finger into each lumen to check that no tissue has been caught between the loops. This should not happen if you have double-barrelled it satisfactorily. If you mistakenly crush his small gut, he will get an ileo-colic fistula. Put the crushing clamp on the spur and tighten the clamp a little. Each day, tighten it a bit more, until it falls free.
When the crushing clamp has fallen off, put your finger into the stoma. The spur should have gone, so that the contents of his gut can pass easily along his colon. Insert your index finger to check that there is a nice big opening between the two loops of colostomy. If there is, close the colostomy extraperitoneally.
Under appropriate anaesthesia (which can be local), infiltrate round his colostomy with adrenalin 1:200,000; wait 5 minutes, make an elliptical incision close to the edge of the colostomy, and prolong it along Lange's lines as shown. With a finger in the colostomy, and with Allis' forceps applied to the skin round the edge of the colostomy, dissect with a No. 11 scalpel blade, or fine scissors, in the plane between his gut and his abdominal wall. Try to avoid entering his peritoneal cavity; but if you do it is unimportant. Lift the cuff clear. Check that the spur is sufficiently deep to allow the faecal stream to pass over the top of it easily. A colostomy is rather bulky, so you may have to sweep his peritoneum away from his abdominal wall a little with your finger to make space for it.
Complete the closure in two layers in the same way as for an intraperitoneal anastomosis, first with an all-coats layer of continuous catgut, and then with a layer of interrupted inverting seromuscular Lembert sutures. The suture line may leak, so put a rubber drain down to it.
If you don't have a proper crushing clamp, either don't use this method, or use a large rubber covered straight haemostat, or Kocher's forceps. Apply them for 15 minutes the first day, half an hour on the second day, and an hour on the third day. By 5[nd]7 days you should be able to leave them on continuously, until they fall off by themselves 2[nd]4 days later. If the stoma bleeds, stop the process for a day.
CLOSING HARTMANN'S OPERATION. See Section 10.10a.
DIFFICULTIES [s7]WITH COLOSTOMIES If his COLOSTOMY RUNS LIKE A RIVER', this is likely to be a good sign in the early stages, because it means that his obstructed gut is emptying itself. If it happens later, give him kaolin mixture with 1 to 2 tablets of codein phosphate 3 times a day. If it happens after you have crushed the spur of a double-barrelled colostomy, you may have crushed a loop of small gut at the apex of the spur and made an ileostomy in error. Refer him to an expert immediately.
If his COLOSTOMY DOES NOT WORK at all, this is likely to be serious. Put a finger into the afferent loop to make sure that it has not become occluded. If this fails to start it, put a glycerine suppository or an enema solution into the afferent loop. If it is still not working after 3 days, he may have a proximal obstruction or ileus.
If the GUT FORMING HIS COLOSTOMY NECROSES (rare), you probably damaged its mesentery by stretching or compressing it into too small a hole. Take him back to the theatre, enlarge the opening in his abdominal wall, and make a fresh colostomy by bringing out more gut.
If his COLOSTOMY WITHDRAWS BACK INTO ITS HOLE, it will contaminate his peritoneum and cause faecal peritonitis, which may be fatal. A glass rod or rubber tube through a loop colostomy should prevent it doing this. To be even more certain, put 6 interrupted sutures between the seromuscular coat of his colon and his anterior rectus sheath (F, and G, Fig. 9-17). When it has withdrawn, you may need to operate to put it right.
If A HERNIA FORMS round his colostomy, it will probably only be a little bulge, and is unlikely to grow big. Prevent it by: (1) not making the opening for the colostomy too big, (2) stitching the seromuscular layer of the gut to the anterior layer of the fascia of his abdominal wall (F, and G. Fig. 9-17).
If his COLOSTOMY PROLAPSES, it will look just like a prolapse of his rectum. Gut spouts out, but you can usually push it back. This is quite common and embarrassing. Prevention is difficult, but the deep sutures mentioned above are some help (F, and G, Fig. 9-17). Reduce it as necessary
If he develops signs of INTESTINAL OBSTRUCTION, adhesions may be forming inside his abdomen at the site where his colostomy emerges, or from the original disease process. They are no different from the adhesions developing after any other abdominal operation. Explore him if he does not improve.
A feeding jejunostomy
The common purpose of an ostomy is to let a patient's intestinal contents get out past an obstruction in his large gut. Occasionally, you may need to make an ostomy in his small gut to let food and drink get in past an obstruction in his oesophagus. Alternatively, you can make an ostomy in his stomach (gastrostomy, 11.8), unless his problem happens to be there.
If he cannot feed himself by mouth, and needs building up, an alternative to total parenteral nutrition (which will probably be impossibly expensive) is to put a tube into his jejunum and feed him through that. Feeding jejunostomies are seldom needed, but they can be life-saving: for example, when a suture line in an injured duodenum needs protecting. To reduce the danger of a leak, introduce the tube into his gut through a long oblique track.
FEEDING JEJUNOSTOMY INDICATIONS. (1) An oesophageal obstruction which is correctable. (2) To protect a suture line in the duodenum following an injury. (3) To protect a suture line in the stomach which has leaked. (4) A pancreatic abscess.
METHOD. Make a small laparotomy in the patient's upper abdomen under local or general anaesthesia.
Find his upper jejunum by following it downwards from his duodenojejunal flexure. Confirm that it is his duodenojejunal junction by finding his inferior mesenteric vein along its left border and feeling it emerge from its fixed position behind his peritoneum. Take a loop about 25 cm from his duodenojejunal junction, and make an incision on its antemesenteric border through the longitudinal muscle layer for about 8 cm. At the distal end of this make a hole through into the lumen. Insert a feeeding catheter (18 Ch for an adult), or a long Ryle's tube, through this hole for about 10 cm. Close his gut around it with continuous catgut, as if you were doing the Lembert suture of a bowel closure (9-6).
Make a second incision in his abdominal wall above where this loop of jejunum will comfortably lie. Draw the end of the tube back through his abdominal wall, as you would with a caecostomy (66-18). Draw his jejunum and the interior of his abdominal wall together with a purse string suture, as for a caecostomy. Close his abdomen and anchor the tube to his abdominal wall with a Saxon stocking' type of anchoring stitch, or with tape (D, to G, Fig. 65-8).
To remove the tube, snip the ligature anchoring it to the skin, and pull. The long oblique tunnel through the mucosa and submucosa will seal rapidly. The purse string anchoring it to his peritoneal wall will prevent his jejunal contents soiling his peritoneal cavity.
Fig. 9-20 MAKING A FEEDING JEJUNOSTOMY. A, making the incision. B, inserting the tube. C, closing the jejunum over the tube with continuous catgut. D, the tube fixed in the gut. E, leading the tube out through the abdominal wall. The inner suture between the jejunum and the parietal peritoneum is not shown.
Draining and closing the abdomen
After a laparotomy a patient's skin has always to be closed separately, either at the operation or a few days later. There are two other layers to be closed: (1) His peritoneum, which is fused to his posterior rectus sheath. (2) His anterior rectus sheath. These layers can either be closed separately in a classical three-layer closure (the skin is the third layer). Or they can be closed together in a two-layer closure (the skin is the second layer) by Everett's or Goligher's methods. These two- layer methods: (1) Are much better at preventing a burst abdomen than the classical three-layer method. (2) Are cheaper: (a) because they are quicker and so save in anaesthetic and staff time, and (b) because they use no catgut. They use monofilament or stainless steel and take big bites which are not too tight, instead of many smaller ones. Everett's method leaves knots on the peritoneal side of the wound where they cause no discomfort.
Delayed primary skin suture will reduce the risk of wound infection in high-risk cases in the same way as in wounds of other kinds (54.1). Antibiotics help, but they are less effective than leaving the skin wound open for a few days.
DRAINING AND CLOSING THE ABDOMEN Before you close a patient's abdomen, make quite sure that, if it is contaminated, you wash it out and instil tetracycline 1 g in 1000 ml of saline or Ringer's lactate, as in Section 6.2 on peritonitis. Drains are not useful, except for localized abscesses, bleeding, or leaks of bile or urine.
SWAB COUNT, etc. Check the operation site thoroughly before you close his abdomen to make sure that you have restored his anatomy as you wish, that there is no bleeding, and no leakage from hollow viscera. Make sure that you have left no instruments, swabs, or packs behind. It is reckless to rely only on a swab count!
ABDOMINAL DRAINS are described in Section 4.10. Read this carefully!
PREVENTING ADHESIONS. Bring his greater omentum down so that it underlies the incision. This will help to prevent adhesions forming between his viscera and his abdominal wall.
EVERETT'S MASS CLOSURE METHOD should be your standard way of closing the abdomen. Take a piece of No.1 monofilament 8 times the length of the incision, fold it in half, and tie a figure-of-8' knot (A, and B, Fig. 9-21).
Pass the needle from the deep surface of his peritoneum, then go from the outer surface of his abdominal muscle inwards on the opposite side of the wound. Thread the needle through the loop, so as to bury the knot.
Go all the way along the wound like this taking deep bites and not pulling too tightly. Place the stitches 1 cm from the edge of the incision and 1 cm apart. At the end of the wound come out from the deep surface, and cut the needle out of the loop. Rethread one end and pass it from outside inwards. Tie the two ends together with a double surgeon's knot, and cut them short. Now either close his skin with monofiliament now, or leave it open for a few days for delayed primary skin suture. This method does not require tension sutures.
CAUTION ! (1) Don't take the bites too close to the wound edges. (2) Don't make the sutures too far apart. (3) Don't make them too tight.
GOLIGHER'S METHOD is for preventing a burst abdomen in the ultimate poor risk case. It differs from Everett's method, mainly in that it preferably uses steel instead of monofilament and the sutures are preferably interrupted instead of continuous.
Gather everything except the patient's skin together with large bites of 28 SWG steel wire. If you don't have wire, use No. 0 monofilament or thicker. Insert the sutures 1.5 cm from the wound edge, and 1 cm apart. Use interrupted sutures only. Tie them with three throws (turns) for steel, and five for monofilament. If you are using continuous sutures (you are advised not to), keep them fairly loose. Close his skin with monofilament now, or leave it open for a few days for delayed primary skin suture.
CLOSURE IN THREE LAYERS is traditional, and is included for completeness. You will find the above methods safer. (1) Use a continuous suture of No. 1 catgut to close the patient's peritoneum together with his posterior rectus sheath. (2) Use continuous or interrupted sutures of 0' monofilament or 28 SWG stainless steel to bring the fascia of his rectus sheath together. (3) Use No. 2/0 monofilament to close his skin and subcutaneous tissues.
TENSION SUTURES are controversial, uncomfortable, and leave ugly scars. Some surgeons never use them, even for burst abdomens, when they use Goligher's method. Others use them when a patient's abdomen has already burst, and no other closure is possible because of oedema and infection.
Place haemostats at each end of the wound, and at 2.5 cm intervals all down the wound before you suture the abdomen. Use them to bring the edges of his abdominal wall together when you tie the sutures. Load up a long curved cutting needle with No. 1 monofilament. Thread a 3 cm length of fine rubber tubing on to this to prevent the monofilament biting into the skin. Insert the sutures through all layers of the abdominal wall, including the skin, taking bites at least 2.5 cm deep on each side of the wound (B, and C, Fig. 9-24). Hold each end in a haemostat. Now suture the wound in the usual way. When you have closed the skin, tie the tension sutures with triple throw surgeon's knots, making sure the rubber tubes lie over the wound itself.
Alternatively, insert the tension sutures as in D, to G, Fig. 9-24. Pass them through all coats including the skin, as is usual for tension sutures, then hold them out on artery forceps ready for tying (D, and E). Put rubber tubes on each alternate suture (F), rather than on each one (as with the usual method). G, instead of tying them across the wound, tie them to their next door neighbours.
Remove the skin sutures first at 9 days, and the deep tension sutures at 12 to 14 days.
DELAYED PRIMARY SUTURE [s7]FOR POTENTIALLY INFECTED ABDOMINAL WOUNDS INDICATIONS. Any kind of sepsis which contaminates a patient's abdominal wound puts him at risk, especially: (1) Caesarean section in the presence of infected liquor. (2) Appendicitis. (3) Perforated typhoid ulcers of the ileum. (4) Perforations of his large gut. (5) The excision of gangrenous gut. (6) Generalized peritonitis.
METHOD. Close the muscles of his abdomen with steel wire, or monofilament. Make the sutures just tight enough to bring the muscles of his abdominal wall together and prevent his gut escaping. Test this as you go along by feeling the inside of the wound with your finger, as if it were a loop of gut trying to escape. Then put a dry gauze pack on his wound, and return him to the ward. If the condition you are operating for demands antibiotics, give them.
At 3 to 5 days, examine the wound. If it is clean, close it by delayed primary closure. If it is infected, apply hypochlorite or saline dressings regularly until it is fit for secondary suture, or secondary skin grafting. Occasionally, you will find the wound already healing so well, that it will close spontaneously. If so, let it do so.
CAUTION ! (1) NEVER close the fascia or muscle of his abdominal wall with catgut. It will be absorbed too soon, and increase the risk of early bursting and later herniation. (2) Don't use braided silk, which increases the risk of sinuses. (3) Make the sutures just tight enough to bring the edges of the muscles together[md]don't strangle them. (4) Don't try to close the abdominal wall and skin in a single layer, except when a burst has already occurred, and you decide to insert deep tension sutures.
DIFFICULTIES [s7]CLOSING THE ABDOMEN If you have DIFFICULTY GETTING HIS GUT BACK INTO HIS ABDOMEN, (1)Ask the anaesthetist keep him well relaxed. (2) Use a fish' as in I, Fig. 10-9. This is a piece of stiff rubber sheet (such as that from a car inner tube) with a tail on it. Place this under the incision to hold his gut down; just as you are closing the incision, pull it out by its tail.
Fig. 9-21 EVERETT'S AND GOLIGHER'S METHODS OF CLOSING THE ABDOMEN. Everett's method A, to J. A, and B, take a long length of No. 1 monofilament, double it and knot it. C, D, and E, catch the end of the loop in the first bite. F, and G, make large continuous stitches. H, and I, open the loop and tie it with a surgeon's knot inside. J, the muscle sutured, and the skin left for delayed primary closure.
Goligher's method, K, and L, is an almost infallible method of closing the abdomen in high-risk cases. Use interrupted wire sutures through all layers of the abdominal wall except the skin. Take big bites and don't tie them too tight. Place all the sutures first and then tie them.
After an abdominal operation
If you have struggled hard to save a patient in the theatre, it is tragic to lose him in the ward afterwards. If you are working under difficult conditions, postoperative care can be at least as difficult as surgery. You will find an ICU (intensive care unit), like that in Primary Anaesthesia, very useful for any ill patient, and particularly for someone who is recovering from a severe operation (A 19.1). The staff of even the simplest ICU should be able to check his vital signs, keep an accurate fluid balance, and watch for postoperative bleeding. If he is recovering from a major operation, he will need need very careful monitoring, and frequent visits from you. If the nurses there are not yet fully trained, you will need to do much of this monitoring yourself. If you don't have an ICU, gather critically ill patients near the nurse's station in an ordinary ward, so that the senior nurse can watch them. The list below of the things she should check is a long one, but most of the checks are quick. Postoperative care is also discussed in Primary Anaesthesia (A 4.6). Above all, try to anticipate complications before they occur.
POSTOPERATIVE CARE THE RECOVERY POSITION. Nurse the patient on his side in the recovery position (A 4-5), with the foot of his bed raised if his blood pressure is low. Turn him 2-hourly.
MONITORING. All patients should be carefully watched, but only a few need careful measurement of their vital signs. The most useful observations are those of the pulse rate, blood pressure, consciousness, skin temperature, peripheral perfusion, and urinary output. If a patient is critically ill, make sure that, during the first few hours, some competent person checks: (1) His level of consciousness. (2) The pattern of his respiration. (3) His peripheral circulation[md]the warmth of his extremities. (4) The capillary circulation in his nail beds, and (5) his pulse. (6) His temperature. (7) His urine output. (8) His degree of pain, and any changes in it. (9) Any bleeding and discharge from his wound. (10) Abdominal distension. His blood pressure need only be measured if these other signs indicate that it might be abnormal, or if he is old, very ill, or has had major surgery.
The nurses in the ICU must be on the look out for: (1) a falling blood pressure and a rising pulse rate, (2) respiratory depression and arrest (A 3.4 and 4.5), (3) bronchospasm (A 3.3), (4) failure of the nasogastric suction to work properly, and (5) the aspiration of gastric contents (A 16.3).
Later, as he recovers, their attention can change to: (1) Maintaining nasogastric suction. (2) Coughing and breathing exercises.
INTRAVENOUS FLUIDS should be managed as in A 15.5. If there is any doubt about the adequacy of fluid replacement, be sure to monitor his urine output. Only a very ill patient needs an indwelling catheter; remove it when it is not absolutely necessary. A Paul's tube is often adequate in men.
If you did not adequately replace the blood he lost at the operation, he will have diluted his blood by the first day, so measure his haemoglobin or his haematocrit, and transfuse him if he is in danger.
NASOGASTRIC SUCTION will prevent the aspiration of vomit; it will remove gas and fluid and relieve distension. Manage it as in Section 4.9.
BOWELS. If he is on a traditional high-residue diet, he will probably have no difficuty with his bowels once any ileus he may have had has subsided. He is more likely to have difficulty if he is on a on a Western' type of low-residue diet. If he has passed flatus, but no stool by the fifth day, consider giving him a rectal suppository.
PAIN. If he is in severe pain, give him half the standard dose of intravenous pethidine or morphine (A 2-4) initially. Give the other half ten minutes later if the first was not enough. A useful method is to add further doses to his intravenous fluids 4 hourly (A 8.9). Or, better, run it in continuously with his intravenous fluids. This makes sure that he gets it all the time without having to call the nurses. Intramuscular drugs are not absorbed rapidly enough. 20 mg of morphine 8 hourly is an average dose for a fit adult. Give half or a quarter of this if he is very sick, thin or malnourished. By 3 to 5 days he should have no need of injectable opioids, so taper them off, and occasionally, if necessary, replace them by an oral opioid.
OTHER DRUGS. (1) Don't give him a hypnotic for 5[nd]7 days, it will not help him while he is in pain. (2) Don't give him an antiemetic without looking for a cause. It may help him if he has an inoperable carcinoma. (3) Continue his perioperative antibiotics only if necessary (2.9). Otherwise, don't give him an antibiotic, unless he has an established infection.
AMBULATION. Encourage him to move his legs in bed. If possible, get him up and about early. Dependent immobile legs have a higher incidence of deep vein thrombosis (rare in the developing world) than raised ones. This is more likely to occur sitting still in a chair than sitting still in bed.
Non-respiratory postoperative complications
Many complications can interrupt a patient's recovery, but you can prevent most of them. Some important ones involve his lungs; these are in the next section. Infections are more likely if he is HIV positive (Chapter 28a).
If he is to recover uneventfully from an abdominal operation, his gut must start to work soon. The passage of flatus and bowel sounds show that his small gut is starting to work; his large gut starts a day or two later. If all goes well, he should start eating in 2[nd]3 days. But eating will be delayed if he is recovering from peritonitis, from an anastomosis of his stomach or upper small gut, or from ileus (10.13), or if he is anorexic from any other cause, such as burns or severe sepsis. If he does not eat he starves, and although he may be able to live for several weeks without eating, he will waste severely. Unfortunately, the common intravenous fluids provide little energy and no protein, and you are unlikely to have the necessary solutions of proteins and amino acids for parenteral nutrition. But if you can get some food into him, as described below, it may save his life.
You are fortunate in that deep venous thrombosis and pulmonary embolism are uncommon in the developing world.
NON-RESPIRATORY POSTOPERATIVE COMPLICATIONS For postoperative bleeding and shock, see Section 3.10. For the anaesthetic complications see A 4.5 and 4.6.
VOMITING If a patient VOMITS IMMEDIATELY AFTER THE OPERATION turn him on his side. It may be due to the anaesthetic, especially ether, or to morphine or pethidine. He is likely to recover quickly. If he vomits for more than 8 hours or copiously at any time, start gastric aspiration.
If he VOMITS AFTER 48 HOURS, this is likely to be more serious, and may be due to ileus, postoperative gut obstruction, or rarely to acute gastric dilatation. If you don't replace his fluids and electrolytes, he will become severely hypovolaemic. He may lose much potassium if he continues to vomit, so replace this (A 15.5).
If he is VOMITING WITH A DISTENDED, SILENT ABDOMEN, he has ileus (10.13). This may be due to postoperative peritonitis (6.2, 10.13) which also causes pain, fever, and toxaemia. The nature of his previous operation, such as a pelvic abscess or an injury to his large gut, usually suggests its site. Later, watch for an abdominal (6.3) or subphrenic (6.4) abscess.
URINE OUTPUT [s7]POSTOPERATIVELY If he passes NO URINE, or only a little, and his bladder is not distended: (1) He may be dehydrated. (2) He may be hypovolaemic. (3) He may have suffered a period of low blood pressure during the operation, which has caused tubular necrosis and renal failure. (4) He may have retention due to an enlarged prostate or a stricture. Some degree of urinary suppression is normal for 24 to 60 hours after major surgery, as a normal response to stress.
If he passes a little urine of high specific gravity, and is obviously dehydrated, give him 1000[nd]2000 ml of saline as rapidly as you can. If his urinary output does not improve, give him 500 to 1000 ml of intravenous mannitol, or 40 to 80 mg of intravenous frusemide. If this produces a diuresis, he was severely dehydrated. If it produces no flow, he may have tubular necrosis and renal failure. If so, go to Section 53.3.
CAUTION ! (1) If he is a child, don't overhydrate him. Give him about 30 ml/kg of fluid for the first 2 hours, and repeat it over the next 3[nd]4 hours if necessary. (2) Before you diagnose anuria, make sure that his Foley catheter is not blocked!
If he passes NO URINE, and he has a bladder which is distended and dull to percussion, he has retention. This is common after perineal operations especially in an old man. Stand him by the edge of his bed, and run a tap. The sound of running water may make him urinate. If this fails, aspirate his bladder suprapubically (entrust this task to the nurses, 23.6). Often it is only needed once. If the problem recurs and provided he has not had an intestinal anastomosis, try carbachol 250[gm]g subcutaneously, if necessary repeated twice at 30 minute intervals. If this fails, catheterize him.
FEVER [s7]POSTOPERATIVELY Most patients have a mild fever for 1[nd]4 days after a major abdominal operation.
If he has more than minimal FEVER postoperatively, suspect pulmonary collapse (9.11), streptococcal wound sepsis (2.10, 9.12), a urinary tract infection (especially if he has been catheterized), a drug reaction, malaria, an abscess either under his diaphragm or somewhere else (6.3), Gram-negative or anaerobic wound infection (54.13), pneumonia, peritonitis (6.2), septicaemia or septic shock (53.4), a subphrenic (6.4) or a pelvic abscess (6.5), or deep vein thrombosis.
If he has PERSISTENT FEVER, and a raised white count, and is not improving, suspect that he has an abscess somewhere in his peritoneum, especially if you operated on him for peritonitis, or infected his peritoneum during the operation. Examine him carefully every day. If he also has a raised diaphragm and fluid in his costophrenic angle, he has a subphrenic abscess until you have proved otherwise[md]see Section 6.4. If he also has diarrhoea with the passage of mucus, he probably has a pelvic abscess. The passage of mucus is a particularly valuable sign. Avoid blind' antibiotic treatment unless his condition is critical. It may merely mask the problem which will become worse later.
FEEDING DIFFICULTIES [s7]POSTOPERATIVELY If his RETURN TO NORMAL EATING IS MUCH DELAYED, he will waste considerably. Here is a variation of the instructions in Section 58.11. Let him eat what he can of his usual staple, such as rice, maize, or potatoes, and supplement this with nasogastric feeding (4.9), using the high-energy milk feed that you usually give to malnourished children. A convenient mix for a litre of feed is: dried skim milk 86 g, sugar 67 g, oil 86 ml, water 811 ml. Or, evaporated milk 443 ml, sugar 67 g, oil 52 ml, water 448 ml. Or, Nespray' 118 g, sugar 65 g, oil 54 ml, water 813 ml. This provides 1370 kcal/l. If he is to recover on this alone he needs at least 2 and preferably 3 litres of it daily. Watch his fluid balance (A 15.5), and give him 10 mmol/day of potassium, which is 10 ml of the commonly used solution (58.11, A 15.1).
If he cannot take fluids by mouth, pass a small plastic tube and start by feeding him 200 ml of a quarter- strength feed every 3 hours. Increase this to the limit of nausea and diarrhoea, until he is having 2 to 2.5 l of full-strength feed in 24 hours.
If he is VERY WASTED , and you have done an operation on his stomach or duodenum, consider feeding him through a jejunostomy (9.7). This is seldom necessary if he can be fed by mouth or by nasogastric tube.
Respiratory postoperative complications
If a patient's respiratory tract is to function normally, it must be kept clear of secretions. After some operations and in some patients this clearing mechanism fails, with the result that secretions accumulate, become infected and infect the lung, perhaps fatally. So you must get him to cough, and bring up the sputum that might otherwise block his smaller bronchi and cause atelectasis. Getting him to cough is most of the purpose of the physiotherapy in the next section.
Anything which will get him moving will help his chest. This may not be easy, but any activity is better than lying in bed. Antibiotics are less important, but he may need ampicillin, chloramphenicol, or tetracycline if his chest infection does not resolve with physiotherapy, or is very severe initially.
If he will not cough, there are various ways in which you can suck out his sputum for him. The last three in the list below[md]cricothyroid irrigation, tracheobronchial suction, and tracheostomy[md]are heroic measures of last resort.
POSTOPERATIVE RESPIRATORY COMPLICATIONS See also Primary Anasthesia' Section 4.6 and Section 9.11a.
RISK FACTORS. A patient is more likely to have respiratory difficulties if: (1) He has emphysema or chronic bronchitis. (2) He has a painful operation site, particularly an upper abdominal or thoracic one, which makes coughing painful, and so prevents him bringing up sputum. (3) He was given excessive opioids or barbiturates. (4) He only recovered slowly from the anaesthetic. (5) He had a high subarachnoid block. (6) He smokes. (7) He is dehydrated, which makes his sputum thick and more difficult to cough up. (8) He is immobile postoperatively as with a fractured femur or paraplegia. (9) He has any other reason for poor breathing postoperatively, such as multiple injuries or a head injury. (10) He is severely ill, debilitated, immobile, or had a prolonged general anaesthetic.
COMPLICATIONS. Here are some of the complications you may have to manage:
If his RESPIRATION IS DEPRESSED, and a tracheal tube is still in place, he should remain in the recovery room until he is breathing normally. Anaesthesia may have been very deep, or he may be very ill. Attach a self-inflating bag to the tube and inflate his lungs. Don't remove the tube until he is breathing adequately on his own. If the tube has been withdrawn, pull his tongue forward and insert an oropharyngeal airway. If this does not restore normal breathing, inflate him with a mask and a self- inflating bag. If necessary, reintubate him, and continue ventilation. If you treat postoperative respiratory depression vigorously, as in Section A 3.4, his lungs are less likely to collapse. If you have a ventilator (A 19.3), use it.
If he is CYANOTIC, WHEEZING, or has an EXPIRATORY STRIDOR; if he is breathing rapidly, with a fast pulse, or if he has vomit on his lips, suspect that he has INHALED HIS VOMIT. Put him in the head-down position. Immediately insert a laryngosope, and intubate him. Pass a sterile suction catheter into his trachea and bronchi. Fill a 10 ml syringe with 0.9% saline or 1% sodium bicarbonate and inject 5 ml down the tube. Turn him to one side, then the other, and then suck the fluid out again. Repeat this until he is breathing easily and quietly. Or, better, bronchoscope him, and suck him out through this (25.12). Give him oxygen. If his respiration is still poor, keep him in the recovery room or the ICU. See also A 16.2 and A 16.3.
If he has BRONCHOSPASM, give him aminophylline 250 mg by slow intravenous injection (A 3.3). This can also be due to the inhalation of vomit, see above.
If he has RESPIRATORY FAILURE with cyanosis, give him oxygen through a face mask with two side holes for his nostrils. If he has a tracheal tube down, give it to him through this.
CLEARING HIS RESPIRATORY TRACT In the following three situtations a patient needs an antibiotic and physiotherapy to clear the secretions from his chest. Tracheobronchial suction, cricothyroid irrigation, and tracheotomy or minitracheotomy' may also be useful.
(1) If he has a cough, confusion, restlessness, fever, tachycardia, cyanosis, rapid or irregular or grunting breathing, with flaring of his alae nasi he has a postoperative lung complication.
(2) If, in addition, he is dull to percussion over the bases of his lungs, usually on the right, with decreased breath sounds and bronchial breathing, low-pitched rhonchi, and X-rays show basal segmental areas of increased density, thick mucus has plugged his smaller bronchi, and caused his lung distal to them to collapse (atelectasis).
(3) If, in addition to the above signs of atelectasis, he has mucuopurulent sputum, rales, and toxaemia, he has bronchitis, bronchiolitis, or pneumonia.
TRACHEOBRONCHIAL SUCTION is useful if he has a bad chest' and you think that he is going to get chest complications after surgery. Consider leaving his tracheal tube in for 24[nd]48 hours, so that you can suck out his chest through it. He will not be able to cough forcefully, but you will be able to aspirate his chest frequently. Before you aspirate, turn him to one side and inject 5[nd]10 ml of saline. This will help to liquefy his sputum and will make suction easier. Turn him on to the other side and repeat it. Be sure there is a Y-connection on the suction tube. Release your thumb from the side arm intermittently to prevent you aspirating too much air, and making his bronchi collapse.
If you have already removed the tracheal tube that he had during the operation, and have done everything you can to make him cough, consider passing a nasotracheal tube (A 13.4), and sucking out his chest through that.
CRICOTHYROID IRRIGATION will usually make a patient cough when he is not inclined to do so. Under local anaesthesia, push a needle and cannula combination (Intracath') on a syringe through his cricothyroid membrane in the midline. Aspirate to make sure that you withdraw air, and then remove the syringe and push the catheter in another 2 cm to be sure it is well inside his trachea. Suture it in place, and plug the opening to make sure that air does not go in or out. Instil 2[nd]3 ml of saline several times a day to make him cough.
TRACHEOTOMY. If other methods of aspiration, including bronchoscopy (25.13) fail; or you need to intubate him for more than 72 hours, consider doing a tracheostomy (52.2), and sucking out his chest through this. If you have bypassed his nose with anything but a minitracheotomy tube (see below), humidify the air he breathes (19.3), if necessary with a steam kettle. It will help him to cough. If you have a steam room put him in it for the first week.
A minitracheotomy' is the most practical way to suck out a patient's trachea. Use a small (4 mm) tube (preferably a disposable Portex' one). Using local anaesthesia with adrenalin in the solution, insert it through his cricothyroid membrane using a guarded scalpel and an introducer. Failing this use a 4 mm paediatric tracheotomy tube and pass a 10 Ch suction catheter down it. A tube of this size is not large enough to obstruct his respiratory tract, there is little bleeding, and the traditional complications of the cricothyroid approach using a large tube (particularly stenosis) are avoided. He can speak, cough, eat, and drink, and humidify his inspired air normally without the need for sedation or anaesthesia. His wound heals quickly with little scarring.
Fig. 9-22 CHEST PHYSIOTHERAPY. A, if secretions are sufficiently liquid you can pour them out of a patient's chest. B, if they are viscid, you may have to shake them out of his bronchi by percussing his chest in the same way that you can percuss tomato ketchup out of a bottle! C, you can lay him with his hips on pillows, so that his hips are higher than his shoulders. D, you can raise the foot of his bed. E, you can sit him up against a back-rest with pillows under his knees. F, you can raise the foot of his bed and put a pillow under his hips. G, if he is too weak to sit up you can rest him against a pillow and lay him on his side. H, you can lay him on his abdomen with a pillow under his hips and the foot of his bed raised. After Hardinge E, and Wilson PMP, A Manual of Basic Physiotherapy', published by TEAR Fund. 9. 11a Respiratory physiotherapy Some simple physiotherapy will often prevent the complications described in the previous section. If an at-risk patient (9.11) is to have an elective operation this physiotherapy should start before the operation. You will probably have no physiotherapist, so you will have to learn these skills yourself, and teach them to your nurses and to his relatives.
PHYSIOTHERAPY CAN BE LIFE-SAVING
RESPIRATORY PHYSIOTHERAPY INDICATIONS. These are the at-risk' patients in the previous section.
PREOPERATIVELY, take the patient through the motions of breathing in deeply through his nose and mouth. Either, sit him up at 70[de] well supported from behind by a back support, and with a bolster to prevent his knees slipping down. Or, lay him on his back with his knees bent.
Put your hands on his chest as he tries to breathe. Give him about 6 breaths only at a time, or he may become dizzy.
CAUTION ! Be sure to explain to him why these exercises are so necessary.
POSTOPERATIVELY, adequate analgesia is a big help. Try to get him to breathe properly, to move about in bed, and to get up as soon as he can.
His position is important; he must avoid the semirecumbent slumped' position, because this restricts the movement of his diaphragm, and promotes the collapse of his lower lobes. Encourage him to sit up with a back support, or lay him on his side sitting up and rolled well forward to free' his abdomen. Get him out of bed and walking on the second day, if you can[md]even if he has a catheter or a drip.
Ask him to do the exercises he has already learnt. An incentive spirometer' is very useful.
Cough him' and huff him' as described below, and ask him to do the same every hour. Start on the day of the operation, visit him twice on the following day, and thereafter once daily.
COUGH HIM'. Distinguish between an effective deep productive cough (which is what you want) and a noise in his throat, which is useless. Several short expiratory huffs' before coughing will help to loosen his secretions. Ask him to take a deep breath after each cough, and not to cough continually without pausing.
If he has an abdominal wound, ask him to bend his knees, to hold the wound, and then to take a deep breath and cough. Or, he can hold a pillow against the wound while he coughs. Reassure him that his stitches will not split. If you wish, you can vibrate him while he coughs.
HUFF HIM'. A huff' is a rapid forced expiration without a cough. If he huffs' when his lungs are full, he will dislodge secretions from his larger airways. If he huffs' when they are half full, he will dislodge them from his smaller airways. So huff him' in both, with periods of relaxation and abdominal breathing between them.
CAUTION ! To be effective a huff' must be long and controlled and not spasmodic. He must use his abdominal wall. The noisiest huff' is not necessarily the best.
PERCUSSION AND VIBRATION. Percuss his thorax over a towel or blanket with your cupped hands for periods of about a minute. Then rapidly shake his chest during expiration. Relax while he inspires, and follow this with some deep breathing. Repeat this two or three times.
POSTURAL DRAINAGE will be useful if there is much fluid in his bronchi. Listen carefully to his chest, and if possible examine his chest X-ray. Decide where his secretions are worst, and arrange him so that this part of him is uppermost, using any of the positions in Fig. 9-23. Ask him to breathe deeply for 10 minutes, vibrate and slap his chest for 10 minutes, then repeat the breathing. If he has established collapse or infection repeat this two or three times a day.
If he is too ill for his hips to be raised, lay him on his side.
If his secretions are viscid, ideally he needs inhalation therapy to loosen' them prior to physiotherapy[md]steam with Friar's balsam, or saline with mucolytics from a nebulizer.
Fig 9-23 POSTURAL DRAINAGE. The positions which allow gravity to promote the drainage of secretions from particular parts of a patient's lung. Study his chest X-ray, and decide which position will be best. Kindly contributed by Lynne Wilson of Killingbeck Hospital, Leeds.
If a laparotomy wound becomes infected
A laparotomy wound usually remains tender for 7 to 10 days after an operation. If it is abnormally tender and indurated, and the patient is also febrile, and does not feel well, he has pus somewhere. His abdominal wall and his peritoneal cavity are two of the places where it can be. Finding it may not be easy, and you can easily overlook an intraperitoneal abscess under a healing incision. Be guided by the severity of his symptoms. More than a little anorexia, fever, and malaise, should make you suspect an abdominal abscess. Antibiotics alone will not cure it. If many of your wounds become infected, try delayed primary closure! (9.8)
POSTOPERATIVE WOUND INFECTION If a patient's wound is red, painful, and tender, and discharges pus, it is infected. Take a Gram stain of the pus, and give him a broad-spectrum antibiotic while you wait for the result of culture, if this is possible. If it is not draining, sedate him with pethidine and diazepam, and start by removing one to three skin sutures on the ward. This will show you the extent of the infection. If it seems to be deeper, but is still extraperitoneal, press the sides of the wound, and probe suspicious areas with sinus forceps. Don't open up the deeper layers of all infected wounds from top to bottom, or remove the deeper stitches. His peritoneum will probably have healed in spite of the infection, but the sutures in the fascial layers will probably pull away. If pus flows adequately, drainage should be adequate. Irrigate his wound with saline or 1/4 strength hydrogen peroxide, or hypochlorite solution. Pack it with dry gauze, or gauze soaked in a mild antiseptic or half strength saline, and change this 1 to 3 times daily.
CAUTION ! (1) Be sure to make a wide enough opening to release the pus. (2) If possible test his HIV status (Chapter 28a).
If his wound SMELLS PUTRID, or you see NECROTIC MUSCLE or fascia, when you remove skin sutures, suspect an ANAEROBIC INFECTION. Give him metronidazole and chloramphenicol.
If his wound is TENSE, SWOLLEN, and BRUISED, with old blood exuding from between the sutures, suspect a haematoma. Sedate him, remove a few of his skin sutures, and wash out old blood and clot with a syringe of saline. Lift out more clots with a swab. Irrigate the wound with saline or hydrogen peroxide, and leave it open for a few days.
If his wound discharges a LITTLE BROWNISH FLUID WHICH SMELLS MOUSEY, suspect GAS GANGRENE (54.13). This is commoner than you probably think. Obvious gas in the tissues is uncommon, so that gas gangrene is often missed. Remove most or all of his skin sutures, make a Gram film of the exudate, and look for Gram-positive bacilli (you are unlikely to have the facilities for anaerobic culture). Treat him thoroughly. Give him benzyl penicillin 10 megaunits daily as four 6- hourly doses for 5 days. And give him metronidazole 400 mg orally and 1 g rectally 8-hourly. Clean his wound with iodine, remove any dead tissue, and isolate him from the other patients.
Burst abdomen (wound dehiscence)
An abdomen which bursts some days after you have sewn it up is a tragedy, because it is preventable, and because the patient has a 30% chance of death. His abdomen is likely to burst if: (1) It is swollen for any reason, such as ileus, intestinal obstruction, or a large tumour. (2) He has severe intra-abdominal sepsis, such as an infected Caesarean section, typhoid peritonitis, or a perforation of his large gut. (3) You have sutured his abdomen with catgut or some other absorbable suture, especially if this is of low quality or out of date, or if his abdominal wound becomes infected. (4) You have sutured it in layers, taking bites of tissue that are too small. (5) He has carcinomatosis, uraemia, or obstructive jaundice.
An abdomen will almost never burst if: (1) You suture it with a non-absorbable sutures, such as steel, nylon, or polyethylene. (2) You close its muscles with one layer of through-and-through sutures, which are not too tight and take wide bites of tissue (9.8). (3) You use delayed skin suture (9.8) if the wound is infected or potentially so.
Fig. 9-24 BURST ABDOMEN. A, a burst abdomen after Caesarean section. B, and C, the usual way of inserting the tension sutures that are sometimes used to prevent this tragedy. A better way of preventing it would have been to use the method of single-layer closure with monofilament shown in Fig. 9-21. D, to G, an alternative way of inserting tension sutures. See Section 9.8. H, a burst abdomen and an intestinal fistula. The tension sutures have broken down. This is a detail from Fig. 9-25. The alternative method was kindly contributed by Mr Brian Sterry Ashby.
BURST ABDOMEN DIAGNOSIS. If a patient's wound is painful about a week after the operation, and he has a thin reddish-brown discharge, his abdomen is probably going to burst. Treat him before it bursts!
TREATMENT. Take him to the theatre, prepared for general anaesthesia. If his abdomen has actually burst, give him a general anaesthetic. Only repair him under local anaesthesia if he is very unfit. If it is a long wound, have blood available. Prepare him for a laparotomy.
Remove the skin sutures in the area where you suspect the burst. Remove the dressings and gently explore the depths of his wound with a sterile gloved finger. Open it down its whole length by removing all the skin sutures. You will soon find out what has happened. If you confirm a burst abdomen, remove all sutures from the fascial layers. Try to insert your finger between his parietal peritoneum and his underlying gut and omentum. In this way you should be able to mobilize enough of his abdominal wall to take some more sutures.
Resuture his abdominal wall with interrupted steel or monofilament sutures, either intermittent or continuous (see Everett's method 9.8). Suture from within outwards through his peritoneum, posterior rectus sheath, rectus muscle, and anterior rectus sheath[md]but not through his skin. Hold all the sutures out on haemostats until you have placed the last one.
Some surgeons also insert tension sutures (9.8), and consider that this is the only indication for them.
If his skin is already infected, use delayed closure (9.8), and graft it later if necessary.
Fig. 9-25 AN INTESTINAL FISTULA. This patient was operated on for obstruction of his small gut by [f10]Ascaris [f11]worms, and a length of it was resected. The anastomosis broke down; a fistula developed. He died a few hours later.
An intestinal fistula is an abnormal track, usually lined by granulation tissue, between the gut and the skin. Fistulae are unusual but serious complications of abdominal surgery, and occasionally arise spontaneously as the result of disease. Beware of postoperative fistulae: (1) After you have divided adhesions for intestinal obstruction, especially if you have opened the gut by mistake, and closed it inadequately, or if it is obstructed distally. (2) When you have anastomosed it inaccurately, or in the presence of tension, a poor blood supply, or local disease. (3) If gut is caught in the sutures, especially tension sutures, when you close the abdomen. (4) After appendicectomy (a caecal fistula). (5) After crushing the spur of a double-barrelled colostomy.
Don't try to operate yourself. Even in good hands the mortality rate of a high output fistula ([mt]1500 ml/24 hours) is 70%, and a low output one 30%. The repair of a fistula is one of the most difficult operations in surgery.
SUDHA (25 years), a young housewife had an operation in a district hospital for appendicitis' through a McBurney incision. Five days after the operation the wound discharged large quantities of pus, and then liquid faeces and gas. She was fed on a low-residue diet, and the skin round the fistulous opening was painted and protected with zinc oxide paste. Absorbent dressings were changed 3 times a day and her distal colonic obstruction due to constipated faeces was treated with glycerine suppositories and a plain water enema. The fistula healed in 2 weeks and she went home. LESSON Some fistulae will close on nonoperative treatment. They are more likely to do so if there is no obstruction distal to the internal opening of the fistula.
INTESTINAL FISTULAE If pus or intestinal contents discharge from the main wound, or the site of a drain postoperatively, suspect that a fistula is forming. If the patient says that gas comes out, this confirms it; so does charcoal, given orally, appearing in the wound, or an X-ray with contrast medium (a fistulogram). If necessary, insert a plastic tube into the track and inject 10 to 20 ml of water-soluble contrast medium.
TREATMENT is supportive.
Replace fluid and electrolytes, orally, intravenously (15.5), or by jejunostomy (9.7). He may need large quantities of electrolytes.
Maintain his nutrition, orally, or by jejunostomy. You are unlikely to have the protein and energy-rich fluids to give him intravenously.
Care for his skin, by keeping the contents of his gut away from it, with adequate drainage, if necessary with a sump drain (4-11), by nursing him prone, as in Fig. 9-13, and by applying karaya gum or zinc oxide to his skin.
Control infection with antibiotics and drainage, when necessary.
Keep his distal colon empty, with saline enemas and glycerine suppositories on alternate days.
REFER HIM if: (1) His fistula discharges [mt]1500 ml/day for [mt]3 days. (2) It has not closed after 3 weeks of non- operative management. (4) He is very ill. (5) It is high[md]oral charcoal appears within 15 minutes. (6) A fistulogram shows communication with his duodenum or jejunum. (7) He does not pass faeces or flatus for 5 days.
THE INDICATIONS FOR OPERATION are: (1) A high output fistula [mt]1500 ml/24 hours. (2) Distal obstruction. (3) A drain abscess. (4) Failure to close after 3 weeks of non-operative treatment. (5) Disease of the fistula track, as with tuberculosis or a foreign body. (6) Intestinal mucosa pouting on to the skin.
Mr Printer. There are two not in series' figures That must be the new doctor' and Mr Y is asking to have his whole gut irrigation with beer' that can be taken in on the first double page spreads in this chapter or the next that would otherwise have no figures.