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Modified Incisions for Laparotomy Dr L a Stimson



DR. L. A. STIMSON, through Dr. Bolton, presented four pa tients showing the results of a transverse incision after lapa rotomy. Dr. Stimson said that in his earlier cases he used a slightly curved transverse incision, convexity upward, crossing the median line a little above the area covered by the hair of the pubes. In the later cases the curve was made in the opposite direction, and in two in which more room was needed it was sup plemented by a longitudinal incision running from the centre of the first towards the umbilicus. The incision is carried through the sheath of the recti, the latter is freed from the muscles up ward and downward, and the abdominal cavity is opened in the median line. This gives sufficient space for most operations upon the tubes and ovaries. If more space is needed it can be obtained by the longitudinal addition mentioned, which is carried through the skin and the Linea alba in the upper part of the space between the umbilicus and pubes. By the aid of this supplementary inci sion he had done in one case a supracervical hysterectomy. The advantage of the incision is in the protection given against the subsequent formation of a ventral hernia, for the recti protect the overlying transverse cicatrix, and the fascia protects the deep longitudinal cicatrix. It seems to be a valuable extension of the principle of Dr. McBurney's intermuscular operation in appen dicitis.

DR. CHARLES L. GIBSON described an incision which for some time past he had used in all abdominal sections in the mid line below the umbilicus. For want of a better term, he called it an incision in "broken planes." The usual median incision is made down to the aponeurosis covering the rectus muscle. The superficial parts are dissected back on one side, allowing him to incise the sheath (only) in a line parallel to the median line, and from half an inch to possibly two inches to its side, say the left. By blunt dissection the sheath is now lifted up towards the median (to the right), allowing of access to the rectus muscle situated the other side of the median line. The rectus muscle (the right one, if the incision in the sheath was made to the left of the median line) is now entered by blunt dissection a suitable distance from the median line, thus constituting the third plane of incision. The transversalis fascia and (if feasible) the peri toneum are opened as a single layer (fourth plane), not directly below the gap in the rectus muscle, but nearer the middle line. When the wound is closed, the lower planes of incision are cov ered directly by a layer of tissue which retains its original in tegrity. Sutures are applied as follows: peritoneum and trans versalis fascia, continuous suture of fine chromicized catgut. The gap in the rectus muscle is closed by interrupted sutures of me dium-sized chromicized catgut passed so as to encircle only the edges minimizing the amount of tissue necrosis. The aponeu rosis is closed with a heavier chromicized catgut suture usually continuous and made with great care to secure a perfect and firm approximation. The superficial sutures are of very fine silk, which cause the least irritation, and if removed early, as they very well can be, leave a scar which in time becomes almost MI perceptible,—a circumstance which often secures the patient's gratitude. He did not pretend to offer this procedure as an im provement on existing methods until an experience of some years should confirm his present belief in its advantages. So far no hernial tendency has manifested itself, and he felt better pleased with its possibilities every time he made use of it.

incision, line, median, muscle, rectus and sheath