In the after-treatment of patients who have undergone grave intestinal opera tions it is questionable whether mor phine should be administered except to relieve the immediate pain; it often tends to aggravate the intestinal disten sion and paresis of the bowel which fre quently follow abdominal operations. '['he administration of a mild saline ca thartic to produce daily liquid evacua tions of the bowel helps to avoid stasis and distension in severe cases. Rectal feeding does not stimulate peristalsis as much as food administered by the stom ach. A supporting stimulating liquid diet is desirable during the first few days. . Enterorrhaphy. — This term is ap plied to the operation of suturing the intestine; it has also been used to designate the operation of joining the ends of the intestine after resection, but "intestinal anastomosis" is a better term for the latter (see below). End-to-end union is termed circular enterorrhaphy.
As suture material, fine silk is almost universally used Catgut, although recommended by some surgeons, swells and stretches and is absorbed too quickly. The needles employed should be round, with no cutting edges, ordi nary straight sewing needles being the best for intestinal work. The methods of suture which have been employed are many, but the following are in general use and suffice for all ordinary purposes.
In the Lenzbert suture, the needle is introduced through about a third to a half centimetre of the intestinal wall on one side of the wound; it is then carried across the wound and introduced in the same way. When drawn and tied this suture brings the serous surfaces into close apposition.
Halsted has shown the importance of carrying the needle through not only the serous and muscular coats, but also into the tough submucous coat. The Lembert suture may be interrupted or continuous, when it is sometimes called l)upuytren's suture. The bert suture is a modification of the Lem bert and is really a Lembert suture in two stages: the first introduced at the edges of the wound through the mucosa, while the second suture serves to invagi nate and bury the first.
In Halsted's the needle is first introduced as in the Lembert suture, then is entered again on the same side of the wound a short distance from its point of exit; it is introduced in the same manner as the Lembert stitch, but passes in the opposite direc tion, thus bringing both the ends of the suture out on the same side of the wound with a loop on the other side; this, when the suture is drawn down, gives a very strong hold on the tissues. The ad
vantages claimed for this suture are that they oppose larger surfaces and more evenly, that they do not tear out as easily and constrict the tissues less than the Lembert suture, and that time is saved by lessening the knots to be tied by one-half.
Whatever method is chosen it is im portant that the serous surfaces be brought into apposition and that the blood-supply of the intestine be studied. The sutures should be so placed that vessels shall not be injured or com pressed, in order that the circulation be as perfect as possible.
Intestinal Anastomosis.—This term is used to designate the operative establish ment of communication between differ ent parts of the intestinal tract, whether the section of gut intervening has been removed or not. The terms ostonzy, etc., are generally used to mean the creation of intestinal anastomosis for the purpose of making a short circuit between healthy intestine above and below, the intervening portion of bowel being left because it cannot be removed or because it is not advisable or not necessary to re move it.
may be performed for carcinoma of the intestine, stricture, agglutination by peritoneal adhesions, for the cure of artificial anus, intestinal ulceration, or other conditions in which it is desirable to put a section of intes tine at rest or to avoid intestinal obstruc tion. It is a procedure of less gravity than resection, and is often preferable to colostomy or the establishment of an artificial anus when the condition of the patient permits. The best results from the operation are seen when it is per formed for unremovable agglutination of the intestinal coils by adhesions. It may be performed by simple suturing or by the aid of various mechanical con trivances which have been devised for intestinal anastomosis.