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Performing Anastomosis of Hollow Viscera by a New Instrument

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PERFORMING ANASTOMOSIS OF HOLLOW VISCERA BY A NEW INSTRUMENT.

A thorough appreciation of the responsibility one takes upon himself when he offers something that differs from the procedures that are in vogue, has prompted me to use every endeavor to find wherein this instrument which I present was weak. I am pleased to state to you, however, that if an error exists in its application I have been unable to find it. I have met with results of the most satisfying character in all of my experimental work on the lower animals. Basing my assump tion upon the knowledge thus obtained, I unhesitatingly offer these forceps to the profession, confidently feeling that, if the forceps are used as they should be, they will win the same con fidence in the hands of others that they have in mine.

My experimental work has gone on for the past nine months, and I can state that I have found the forceps in their application to possess advantages not to be found in any of the methods now in use. To briefly mention some of these advan tages: First of all is the wide application of a single instru ment : with the same instrument one may do a resection of the pylorus, of the cmcum, and of the small or large intestines. Anastomosis can also be performed on any of the hollow viscera, including the large and small intestines, stomach, and even intestines of unequal calibre; the various gall-bladder ' Read before the .Philadelphia Academy of Surgery, May 7, 1900.

operations can also be performed. In fact, I cannot conceive any of the gastro-intestinal operations that cannot be per formed by the use of this instrument.

An exceedingly strong factor in favor of the forceps and method is the manner of closing off the bowel cavity at once; this is the first step in all operations where the forceps are em ployed, the bowel remaining closed until the very last moment; when the forceps are removed it is through a very small open ing, an opening so small that it is under the thorough control of the operator ; thus the dangers of fecal matter escaping into the peritoneal cavity are prevented.

Rapidity is an essential factor, where such rapidity does not sacrifice careful and accurate work. A method the speed of which is not at the expense of accuracy, is the only method one can consistently use in gastro-intestinal surgery, and it pleases me to say to you that the speed of my method has not been at the expense of accurate work.

In comparing this method with the Murphy button opera tion, it may take a moment or so longer ; but I think the extra time spent in forceps approximation of the bowel is well spent when one considers the very decided advantages gained. It is certainly more surgically complete than leaving a foreign body in the intestinal canal, which causes no little anxiety until the patient has voided it.

Secondary stricture of the bowel is another important matter for consideration in this class of work. The dangers of this complication are reduced to the minimum in the method under discussion.

The calibre of the bowel is not impaired in the least de gree, as the bowel is spread out to its fullest extent, without stretching, by the forceps before sutures are introduced. As to the amount of gut inverted, this, I think, causes no difficulty if it be within reasonable bounds, as in a very short time it undergoes an atrophy ; in fact, in my dog work, I was sur prised to find that this atrophy occurred in several cases to such an extent that in a week's time one could hardly find any trace of the gut that was inverted. In these cases I turned in about a half an inch, which was more than was required, and on examination a week later I could only find about a sixteenth of an inch projecting into the lumen of the gut.

I need not dwell upon the necessity for accurate suturing to obtain successful results in all bowel work. In comparing this method with some of the other artificial means to assist in suturing accurately, such as the inflatable rubber bags, all that is needed is for one to see the forceps used to be convinced of their superiority. A test that I have employed to satisfy myself of the accuracy of my suturing has been to tie one end of the sutured gut, place the other end on a faucet and turn the water on ; if I had used ordinary care, no leakage would occur at the line of suturing, the stitches tearing out before any leakage would occur. This procedure is about as severe a test as one could employ, certainly in the human subject the strain is never so great as this.

To summarize the points of advantage claimed for this method : (I) Reduction of the dangers of sepsis.

(2) Rapidity.

(3) Accuracy.

(4) Wide range of application.

( 5) Simplicity.

These I would term the cardinal points to success in gas trointestinal surgery as well as in gall-bladder surgery.

The instrument consists of two pairs of straight forceps, the jaws of which are very slender and two and a half inches long, for ordinary work ; for special work they can be made longer. Instead of being roughened as in the ordinary hwmo static forceps, they are grooved down the centre of one blade ; the opposite one has a ridge, similar to a pile clamp ; both for ceps are held together by means of an adaptation of the serre fine.

Method of doing a Resection, followed by an End-to-end Anastomosis. The serre-fine clamp is removed, and one for ceps is placed transversely across the bowel at the point selected to mark the upper border of the resection, and locked ; the

forceps, method, bowel, suturing, surgery, gut and application