Against such benign eases we must mention those in which the mesenteric vessels are tightly constricted within ten hours and the circulation entirely shut off. The gangrene in these cases prevents reduction (Fig. 144).
We see from this that we cannot draw definite conclusions from the symptoms as to the extent of the anatomical changes and that the immediate operative exposure of the invaginatcd part is the only safe procedure. If a high irrigation does not loosen the loop at once, then it would be criminal to wait longer with the operation.
The best procedure would be as follows: Light narcosis, only enough to relax the abdominal wall, careful examination, deep palpation during expiration and bimanual examination from the reel U111, high enema, at the same time preparation for an operation. Should the enema not suc ceed in reducing the invagination, which we can easily feel through the relaxed abdominal wall, then we proceed at once with opening the abdomen and bringing the tumor into view. Hero again we must avoid all eventration, only the invaginated part is brought out of the abdomen, the other loops are returned at once. We now proceed with the manual loosening in such a manner that the tip of the invaginated part is slowly pushed back. All pulling on the invaginatcd intestine must be avoided on account of the (hanger of its tearing. If we are unable to loosen it, or should we observe gangrenous places, then we must decide to remove a piece of intestine, which, however, gives an unfavorable prognosis in children. Infants especially rarely survive this.
Manual reduction is therefore mostly to be desired, because it is easier to save a child when the serous coat has been torn and when we have to leave some suspicious spots, which we may carefully cover with omentum, than when we had to do a resection.
The technic of resection is determined by the location of the invagi nation (small intestine, mcum); as a rule we will succeed with the ordinary methods of abdominal surgery.
An exception is the resection according to Jesset-Barker, who tries to reach the intussusception through a longitudinal incision in the invaginating gut; he then applies a circular suture through this incision and extracts the invaginated part, thus imitating the occasional spon taneous cure, in which the intussusecption becomes necrotic owing to the constriction of its mesenteric vessels and is passed out through the intestine, while the intestine heals at the line of demarcation without perforation into the abdominal cavity.
The chances of recovery from resection of the gut improve with every year of life. Thus we succeeded in a boy six years old, in whom the invagination was caused by a sarcoma at Bauhin's valve, in making an anastomosis after resecting the ascending colon and a piece of ileum, though the prognosis was quite unfavorable owing to the location of the resection (large intestine) (Fig. 192a, 192b, Plate 21).
The resections made necessary by congenital occlusions and mal formations usually end fatally; still we must attempt to make a perma nent cure by eliminating a piece of intestine or by anastomosis rather than give temporary relief only by making an artificial anus; because this latter procedure only means putting off the inevitable, as we will hardly ever succeed in preserving life by this, but it may enable us to defer radical operation to a more favorable time.
lkus from strangulation will also give a fair prognosis in children when it is relieved in time, before it has caused peritonitis or detnands a large resection. We must always think of the possibility of an ileus from the strangulation of a Mockers diverticulum, especially in cases which present other congenital malformations; also of strangulation from a healed tubercular or purulent peritonitis with adhesions (see tubercular peritonitis).
The megarolon congenilum (Hirsehsprung), Fig. 146, would require the elimination of the whole of the eolon, which operation has been tried repeatedly and was successful in one reported case. The anastomosis of the ileum with the rectum requires both considerable technical ability and a very resistant patient.
The technic of all these operations—artificial antis. intestinal resec tion and extensive plastic surgery of the intestine—is identical with that in adults, but we must always remember that the long time consumed in the operation and the protracted narcosis be fatal to the child. Our motto in all abdominal operations in children must therefore be to work as simply and quickly as possible. We must avoid all eventra tion and chilling of the intestine, because this will cause fatal shock in children. We must attempt to do all our manipulating extraperitone ally, so as to interfere as little as possible with the vitality of the peri toneum. Only under these conditions can we count upon good results in abdominal surgery in chihlren.