THE OPERATION OF INTESTINAL RE SECTION.—The parietal incision is usu ally made directly over the portion of intestine about to be removed or just above it. But for resection of the small intestine the incision should never be much below the umbilicus and in most cases would preferably be above it, for greater freedom will be gained in bring ing the bowel out of the incision if it is made nearer the mesenteric attachment, which is above. An exception is found, of course, in cases of gangrene from strangulated hernia in which the in cision is made directly over the seat of strangulation. For excision of the ca: cum an incision in the line from the an tero-superior spine toward the costo spinal angle will be most convenient. The first part of the incision is best made short; then after the growth is ex amined it may be prolonged in the direc tion which is likely to prove most satis factory for its removal.
In case of grave operations an incision sufficiently extensive to give free access to the field of operation is essential. After opening the abdomen the bowel should be brought out of the incision and surrounded with gauze pads wrung out of hot, sterile, salt solution, the pads being changed as soon as they cool. The growth should be carefully examined before proceeding to remove it. In case of malignant disease resection is visually considered contra-indicated if the mesen teric glands, except in the area attached to the bowel, are affected. Konig, however, has reported several very ex tensive operations in which the growth had involved surrounding tissues, and in which removal was not followed by re currence for two years or more. The in testinal contents should be pressed away from the area of operation so as to leave the intestine collapsed and empty. The portion to be reseeted should then be isolated by means of some form of in testinal clamps. The blades of the latter are usually covered with rubber tubing to minimize the risk of injury, and they should be placed obliquely in the direc tion of the ,blood-vessels, so as not to damage them. If no clamp is available, a flat sponge may be folded around the bowel and a ligature tied over it, after perforating the mesentery. Two strips
of iodoform gauze are also very efficient and always at hand. Two clamps are usually sufficient, except in operations on the colon, which it is difficult to empty. In this case a clamp is placed on each side of the line of incision and the bowel divided between. The mesentery is cut as near the bowel as permissible, instead of in a wedge-shaped piece, as has been sometimes recommended, as this involves less division of the vessels and smaller risk of gangrene. Sharp-pointed forceps are desirable in seizing blood-vessels of the intestinal walls in order to avoid un necessary crushing. It is specially im portant to determine with certainty that the intestine is abundantly supplied with blood through the mesenteric vessels on each side of the reseeted area. If the blood-supply is doubtful it is much bet ter to resect a larger piece of intestine until a good blood-supply is found. After the diseased area. is removed the ends of the intestine may be united by simple suture according to any of the methods mentioned under intestinal anastomosis, or by the aid of such me chanical means as may be considered de sirable. Creig-Smith recommended that in case of malignant growths causing considerable obstruction, an artificial anus be first established and the bowel thoroughly unloaded, flushed, and cleansed. Then the resection may be performed at a subsequent operation.
Morlalily.—The mortality after resec tion for gangrene will depend upon the condition of the patient and the bowel at the time of operation: it has been estimated at from 12 to 50 per cent. The mortality after operations for ma lignant growths has been high, very likely because of the weakened condi tion of the patients: it has been esti mated at from 23 to 50 per cent. Prob ably the average mortality is not over 30 per cent. if all cases were included, and it may be hoped that, with more careful methods of diagnosis and the more fre quent resort to early exploratory opera tion, the results will be much improved.