MECHANICAL DEVICES TO AID IN IN TESTINAL ANASTOMOSIS.—In addition to the method of anastomosis (uniting the intestines directly by suture), many me chanical means have been devised to aid in the rapidity and accuracy of the pro cedure, such as buttons, bobbins, cylin ders, collapsable bulbs, anastomotic for ceps, etc. The most commonly used of these, is the Murphy button. In using the Murphy button a purse-string suture is put around each of the openings which it is desired to anastomose, beginning at the point farthest from the mesentery and taking one overstitch at the mesen teric junction to make certain that both layers of the peritoneum overlap. Each half of the button is introduced by for ceps into the bowel, and the puckering sutures are tied closely upon the stems; the halves of the button are then locked by pushing them together. If the bowel is properly gathered around the stems, the flanges, pressed together by the spring inside, will keep up an accurate apposition of the serous surfaces of the bowel. The chief advantage of the Murphy button is the rapidity with which it can be used; the disadvantages are the possibility of imperfect union, with resulting leakage of intestinal con tents and septic peritonitis and the pos sibility that the button may not pass from the intestine, but may give rise to ulceration or intestinal obstruction.
With no other method of intestinal approximation can he obtained all the desired conditions in such ingenious combination as with the mechanical de vices of the Murphy type. The chief advantages of such devices are, it is stated: (1) simplicity of application; (2) saving of time; (3) uniform coapta tion of the peritoneal surfaces of the entire circumferenees of the approxi mated ends; (4) prevention of bleeding at the seat of approximation; (5) a cicatrix that will not contract to a se rious degree; (6) exact juxtaposition of histological structures; (7) minim izing of risk of infection, as no needle is used to carry infection from the intes tinal canal into the peritonea] cavity. There is also a reduction of mortality. According to statistics with mechanical methods of the Murphy type, the mor tality in gast•o-enterostomy for non malignant disease ranges from 2.5 to 14 per cent., in end-to-end union from 10.5 to 16 per cent.; and is only as high as :13 per cent. in malignant cases. With the suture methods the mortality ranges in from 24.5 to 76.47 per cent., and in end-to-end ap proximation from 5S to 100 per cent. Frank (Annals of Jan., 1002).
The anastomotic forceps which were devised by Laplace, and have since been modified by Downes and others, offer a means of rapidly and accurately sutur ing without. leaving any foreign sub stance within the gut. The forceps re semble two pairs of haemostatic forceps held in apposition by a clasp. The blades of each half are semicircular in shape, together forming a complete double circle, between which the por tions of intestine to be united are held. If the serous surfaces of the intestine do not tend to invert over the blades as the forceps are closed, they should be adjusted so that this I be accom plished. Continuous or interrupted
sutures may be applied according to the preference of the operator. After the sutures are inserted the clamp is re moved; first one-half of the forceps is carefully opened and removed, then the other is removed in the same manner.
One or two sutures are sufficient to close the opening occupied by the forceps and complete the operation.
A new forceps for intestinal anasto mosis may be described as follows: The forceps consists of two parts, which are really haemostatic forceps, curved into a semicircle on each side. only held together by means of a clasp, they open as two rings. They are opened within the intestine, and serve the same purpose as Senn's rings or any other ring that has been devised, bringing serous mem brane to terous membrane. Accurate suturing is the operation of the present. Therefore, if these forceps are within the gut, and sutures are applied, as they would be with the help of Senn's rings. it follows that sutures are introduced all around, except where the forceps pene trate the parts that are sutured. The suturing being done. the forceps are re leased by loosening the clasp, and then withdrawing the forceps out of the small opening: first one-half, then the other, when the operation is finished by a stitch or two. This forceps will serve for the operation of end-to-end anastomosis and also of lateral anastomosis. Ernest Laplace (Annals of Surg., _liar., '99).
Original forceps for making intestinal and visceral anastomoses. The instru ment is a small one and possesses the advantage of requiring 110 additional in strument or even the hands of an assist ant to prevent contamination of the wound surfaces with fecal matter dur ing the anastomosis. 31. O'Hara, .Tr. (Annals of Surg., Feb., 1901).
In the use of Senn's decalcified-bone plates or the various rings of catgut, raw hide, etc., which have been employed, the plates arc introduced into the open ing which it is desired to anastomose, threaded with four needles, and the sutures are passed out through all the coats of the bowel a little way from the edges of the intestinal openings. The intestinal surfaces are usually gently scarified to accelerate union; the liga tures in the plates are tied with the in testinal walls invaginated between them, and a reinforcing continuous suture, inserted over the edges of the rings or plates, completes the operation.
Maunsell's Method.—In this procedure two temporary sutures are employed to make preliminary approximation; these are tied and the ends left long. A longi tudinal incision an inch and a half long is made in the larger segment of intestine opposite the mesentery and two inches from the divided extremity. Through this opening a pair of forceps is passed, the free ends of the sutures are caught, and the cut ends of the bowel are brought out through this opening. The two tem porary sutures are held while the ends of the intestine are united by through-and through suture. The temporary sutures are then removed, the invagination re duced, and the edges of the longitudinal incision are closed by Lembert sutures.