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Intestine

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INTESTINE.

The instrument which I wish to describe is an improved device for holding the cut ends of an intestine in position while they are being sutured. The instrument can be readily ad justed to fit any intestine, and any desired tension or relaxa tion may be given to the parts during operation. As soon as the suture has been completed, the instrument may be made to collapse, and thus may be drawn from the intestine through a very small opening.

Before describing the features of construction and parts in detail, it might be well to review and to take into considera tion the devices of this kind which have been suggested and used up to the present time.

The difficulty of intestinal suture was recognized as early as the thirteenth century, when the so-called " suture of the four masters" was introduced. This consisted of a trachea of a goose being inserted into the lumen of the bowel and the ends of severed intestines being brought into position upon it. The ends were then sutured with four interrupted stitches, which did not include the trachea. Dr. Verger, in the eighteenth century, again brought this procedure into prominence by reporting a successful case.

As soon as abdominal surgery became generally recog nized, many devices, based upon the same principle, were pre sented to the profession. Sabatier employed oiled card-board ; Guy de Chauliac made use of dry gut as a support; Watson isinglass ; Walter, gum resin ; Holenhauser, dough ; Clark, a bobbin of India rubber ; Pilcher, a potato bobbin ; Wacker hagen, digestable wafer cylinders, and Metcalf, a candy ap proximator.

Then came the various methods by use of decalcified bone, as suggested by Neuber, Willy Sachs, Mayo, Robinson, Bailey, Allingham, Hayes, and Ball.

Then there was the innovation of the removal of the foreign body before the suture was completed, as with the inflated rubber bulbs of Frederick Treves, Reder, Downes, Halsted, and Wackerhagen. In the last instance the rubber bulb was not removed but was perforated, allowed to collapse and pass away with the fecal current.

One of the most recent developments in this line is the employment of a mechanical contrivance with the object of holding the intestine in position while the suture is being in serted, and then its removal before the suture is completed ; such as the clamps of Mudd, Grant, Morrison, Laplace, Mc Lean, Downes, Ferguson, and O'Harra. These instruments, with the rubber bulbs, are the ones most used at the present time. It is not my purpose to give a detailed description of these various instruments or to discuss their many advantages or disadvantages. The following points may be spoken of, however, in contrasting them with the instrument presented in this paper : (I) One instrument will fit all sizes of intestine, whereas, in the above clamps, a set of instruments of different sizes is necessary.

(2) In the above-mentioned clamps and rubber bulbs, the operator is limited to the use of certain sutures, principally the Lembert suture; whereas, with the author's holder, any method of suture may be used.

(3) There is no necessity for any preliminary retention sutures, such as are used with the bulbs and many of the for ceps.

(4) No assistants are necessary to complete the suture.

(5) There is not such a tendency to diaphragm formation during and after suture as with the methods such as the Laplace forceps and its various modifications.

The instrument in features of construction and combina tion of parts is fully described by the accompanying drawings. Fig. i is a longitudinal section of the instrument, showing it in position when in use. Fig. 2 is a view similar to Fig. i, showing the parts in their folded or collapsed condition. Fig. 3 is a sectional view on line 3, 3, of Fig. 2.

The instrument consists primarily of two pairs of pivotal arms (i and 2) forming, when extended, what might be termed a double cross, and adapted, when in this position, to have the cut ends of the intestines extended over them. The outer surfaces of the arms, which come in contact with the in testine, are serrated in order to prevent any movement of the intestine after it has been placed on the instrument in position. These arms are adapted to be separated, as illustrated in Fig.

in dotted lines, in order to fit any sized intestine, or to give any required tension or relaxation to the intestine during the suture. The arms (1) are pivoted to the end of the handle or stein (3) of the instrument with a hinge-like joint, the back of the arms being adapted to bear on the shoulder (4) on the end of the stem (3) when they are extended at right angles to this stem, and thus they are prevented from being forced beyond the right angle position, and at the same time are free to be moved into the position shown in Figs. 2 and 3, where they practically form an extension of the stem (3).

Stem (3) is provided with a slot (5), within which arms (2) are adapted to lie when closed to the position shown in Figs. 2 and 3.

In making said slot (5), a central wall or wedge-like tongue (6) is left extending from the end of stem (3) to which the arms (i) are pivoted.

Arms (2) are pivotally mounted upon the end of an inner member (7) which is mounted in a tube (8), being mounted within the stem (3), and is free to move endways, but is prevented from being turned around by means of the wing or key (9), which is fastened rigidly to the wall tube (8) about midway of its length.

Key (9) is adapted to slide within a key-way or slot ( io) which is formed by cutting away the wall of the stem (3) from the end of slot (5) to the outer end of said stem.

Arms (2) are held in their extended position by means of tube (8) which is adapted to be forced against the inner ends of arms (2) when they are in their extended position, by means of the nut ( ) which is mounted upon the outer end of member (7), and is adapted to be screwed against the outer end of this tube. The outer end of tube (8) is provided with a slight enlargement or ring (12) to provide a suitable shoul der against which nut (I r) is adapted to bear. In order to prevent nut ( ) from moving too freely on member (7), the outer end of member (7) is split and the two parts are sprung outward a trifle, as shown in Fig. 2.

To provide for moving arms (2) away from arms (i), as indicated in dotted lines in Fig. t, a nut (i 3) is mounted upon the outer end of stem (3), adapted to be screwed against the inner end of key (9), the various parts being in positions shown in full lines in Fig. 1, and force-tube (8), member (7) and arms (2) away from arms ( 1).

In using the instrument, the various parts are first brought to the position shown in full lines in Fig. 1; the ends of the intestine to be joined together are then placed over the arms, the edges to be joined being brought together over a central line, except when they pass adjacent to the stem (3).

The arms ( ) and (2) are then separated, as has been described, to give proper tension to the intestine, when the ends are secured in the usual manner.

To withdraw the instrument from the intestine, the nut (ix) is backed off the tube (8), withdrawn from contact with said arms (2), which are then free to collapse towards and into the slot (5). The members (7) and tube (8) are then withdrawn through the stem (3) until arms (2) lie wholly within the stem (3), as shown in Figs. 2 and 3. Then, as stem (3) is withdrawn from the intestines, arms (I) take the position shown in Figs. i and 2, and are easily withdrawn.

As before mentioned, any method of suture may be used in connection with the holder, i.e., single or double, continuous or interrupted, penetrating or not penetrating the entire thick ness of the bowel. Among those to be recommended are those of Lembert, Czerny-Lembert, Gussenbauer, Greig-Smith, Halsted, Cushing, Woelfler, Maunsell, and various other modi fications. In describing the use of the instrument in connec tion with a special suture, I have chosen the Connell stitch, as I believe, when properly inserted, it is followed by ideal results. In using the Connell suture, I deviate from the origi nal method in several ways; the principle of the suture, how ever, is maintained, i.e., a single suture penetrating all coats of the bowel, in which all knots are placed within the lumen of the bowel. I differ in the following points: (z) The mesenteric stitch is inserted in a different man ner. (Fig. 4.) (2) All suspending loops are dispensed with, the holder being substituted, so that only one thread is used throughout the entire procedure.

(3) The bowel is divided into two sections by the holder (Fig. 7), instead of into three, as with the suspension loops.

(4) A continuous suture is used in place of an interrupted one. This, however, is simply a matter of choice or conveni ence.

Before placing the holder into position, the mesentery is treated as follows : After threading two intestinal needles with a long piece of silk, a needle at each end of the silk, one of the needles penetrates the entire thickness of one end of the bowel, from within out, very close to the centre of its mesenteric border, so that when it emerges from the bowel it enters into the mesen teric triangle formed by the two folds of peritoneum and the bowel wall. The peritoneum is now picked up by the needle close to the apex of the triangle ; then the peritoneum of the opposite end of the bowel is included in a corresponding posi tion, after which the needle enters this end of the bowel, pene trating all coats, as it did in the first end. (If the thread were now to be tied, the knot would ride directly over the juncture of the incised mucous membrane of both ends of the bowel, leaving both the mesenteric spaces or triangles still gaping.) The needle is now returned to the first end in the same manner, the peritoneum on the opposite end being included in the suture, the stitch running very close and parallel to the first insertion. (Fig. 4.) The mesentery should divide the thread into two equal parts, after which it is tied.

In tying, those portions of the bowel wall of both ends, which are included in the stitch, are drawn into the triangular spaces, or vice versa, the triangular spaces are drawn over the bowel walls, and are thus obliterated. The knot is on the in side of one end of the bowel, and there is a continuous layer of peritoneum across the line of the mesenteric approxima tion (Fig. 5), restoring it to its normal relations. The needles now penetrate the bowel wall close to and on either side of the knot. (Fig. 6.) The intestine holder is now introduced into the bowel, so that the distal arms ( ) are placed along its mesenteric border; and the other arms (2), when holding the intestines under proper tension, are directly opposite the mesenteric at tachment, thus holding the intestine in a flattened condition and dividing it into two halves. (Fig. 7.) Care should be taken to push enough of the intestine over the arms so that there is little or no tension at the ends of the arms. When the intestine is thus held in this position by the holder, the threads may be seen protruding from either side of one end of the intestine close to its mesenteric border. (Fig. 7.) One-half of the intestine is now sutured. With one of the protruding threads a right-angled continuous suture is used, which includes all coats of the bowel. (Fig. 7.) As the stitches are inserted the thread is pulled taut, so that the inserted thread disappears from view, assuming a subperitoneal position. (Fig. 8.) As soon as the point is reached where the stem of the holder protrudes from the lumen of the gut, the final stitch, which is a half-stitch, is taken to the opposite side, a stitch from without in, and one which remains in the gut. (Fig. 8.) This final stitch is very close to the corresponding final stitch of the other side of the intestine, which also pro trudes through the same end of the bowel.

The instrument is now turned to the other unsutured side of the intestine, which is now sutured in the same manner as the first one. (Fig. 9.) The instrument is made to fold and is withdrawn through the very small remaining opening. The final knot is now tied, as described by Connell.

As is shown in Fig. 1o, the two loose ends of the thread are ready to be tied within the lumen on the same side of the mucous membrane. Fig. i i demonstrates the next step, the tying of the ends, with knot on the mucous membrane. A needle armed with thread is inserted, eye first, from the oppo site side in the line of the previously tied stitches, and made to present near the two ends of the stitch to be tied. The thread of the eye of the needle is then loosened sufficiently to form a loop, through which the end of the inserted stitch is passed.

The needle with its thread is then withdrawn, bringing with it on the loop the three ends of the stitch to be tied.

Fig. 12 illustrates the ends, ready to be tied, presenting on the extreme surface of the bowel in the line of union. When traction is applied to these threads the bowel is flattened, thus bringing the mucous coat on which the knot will be located in close contact with that of the opposite side. The ends are tied finally in a square knot and then cut off close. Upon manipu lating or slightly stretching the gut, the final knot will slip into the bowel in the proper position. Fig. 13 shows the suture completed, all of the knots on the mucous membrane, and the suture invisible from without.

fig, arms, suture, bowel, position, instrument and stem