END-TO-END ANASTOMOSIS OF THE INTESTINE.*

BY J. L. JOHNSON, M. D.

Having perhaps observed in the June number, 1896, of the New York Polyclinic and in other medical journals of that date a brief description of my operation for end-to-end anastomosis of the intestine, you will, I am sure, not be averse to a more complete explanation of its technique.

In other words, I wish to present to you my recently devised method of end-to-end anastomosis of the intestine. I say recently devised, yet as previously intimated, more than two years have elapsed since in the operating-room of the New York Polyclinic I originated what has been pronounced by the surgeons of that famous institution an ideal technique.

During the interval which has elapsed since the period referred to I have been engaged in an extensive post-graduate course in the famous hospitals of the Old World, and during that time I demonstrated this operation before the Surgical Society of London, and to many surgeons whose names are famous throughout the civilized world, among whom I will mention: Mr. Treves, of the London Hospital; Mr. Allingham, of St. George's, and that noble Scot, Macewen, of Glasgow, and last, but not least, that intellectual giant, the late Pean, of Paris, all of whom united in its praise.

Since returning to my native land I have been constantly urged by various professional friends to place this technique more effectively before you, consequently I avail myself of this opportunity to do so.

As an introduction to this paper I deem it expedient to refer to a few other methods to which in the past we have resorted in intestinal anastomosis.

Dennis, in his admirable work, refers to this subject as follows: Suturing of the intestines may be regarded as both ancient and modern. Intestinal suturing is mentioned by Celsus in the first century of the Christian era, also by Abul Kasum, one thousand years later. The earliest definite writings on the subject, however, were by Italian surgeons during the middle ages. Guilielmus de Salicelo about the year 1500 is said to have used a segment of dried gut over which he sutured the bowel. He afterwards used the trachea of a goose, in a similar manner, to keep the lumen of the bowel open. This work was

*Read before the Southern Kentucky Medical Association, 1898.

very soon forgotten, and at the beginning of the nineteenth century Dr. Virgir used practically the same methods, and regarded them as original.

"The old technique practiced by the majority of surgeons was to bring the divided ends of the intestines into the abdominal wound, and retain them by sutures to prevent extravasation of feces into the peritoneal cavity.

"Schacher, of Leipsic, in 1720 is said to have been the first to do this successfully in man. Later the surgeons attempted to hold the wounded bowel against the abdominal wound by passing a suture around the bowel and through the mesentery, thus anchoring it to the abdominal incision.

"The first successful case of end-to-end anastomosis of the intestine was that of Ramdohr, in 1780, who invaginated the upper end of the

CYLINDER.

FIG. 1.-Cylinder ready for use.

divided bowel into the lower, and secured it with a single suture, joining the bowel to the abdominal wall.

"Bell invaginated the bowel over a cylinder of tallow.

"Ammussat used a hollow cylinder of elder containing a transverse

groove.

"Neuber used a cylinder of decalcified bone, with a deep groove in its center, over which the ends of the bowel were sutured.

Chopart and Desault used a cylinder of cardboard, over which the bowel was fastened with a single suture.

"All these methods are erroneous, because they approximated mucous to serous membrane.

"During the second and third decades of this century the proper mode of intestinal anastomosis was begun. Travers first experimented on animals, and met with such success that he published his work in 1812, entitled 'An Inquiry into the Process of Nature in Repairing Injuries

of the Intestine,' which was a valuable contribution to the knowledge of intestinal repair. Modern methods proper, however, began with the labors of Lembert, he being the first to call the attention of the surgical world to the fact that it was the contact of serous surfaces which was necessary for union to take place. These facts were given by him to

the world in 1825-6.

"Intestinal anastomosis may be spoken of under two heads: First, without mechanical aid. Second, with mechanical aid."

You are all perhaps aware of the great difficulties encountered in doing an end-to-end anastomosis without some support to the gut.

Maunsell, recognizing this fact, devised, as he thought, a better plan; but as we all know, it, too, has its serious disadvantages, the slit in the bowel and the through-and-through sutures being prolific sources of sepsis. "Recent mechanical aid to intestinal suture and anastomosis began in 1887 with Senn's decalcified bone plates," which a decade since flashed upon our professional vision, has long since disappeared beneath the horizon, leaving scarcely a glimmer of their once promised glory. "Senn may be called the pioneer of this department of surgery; but, as above stated, his lateral anastomosis has fallen into. disrepute; because of the difficulty in obtaining decalcified bone of sufficient size to enable a surgeon to get an opening large enough for the passage of the contents of the bowels."

An interval now elapsed, which may be called the dark ages of modern intestinal surgery, when another lurid glare flashed athwart the surgical world, heralding the birth of Dawbarn's lateral anastomosis, who it is claimed did the first intestinal work with the aid of vegetable plates, publishing the result of his labors in the New York Medical Record, June 27, 1891. After blazing the comet of a season, this most unsurgical operation too found an untimely end.

Lateral anastomosis should never be done by choice, and should never take the place of the end-to-end operation. The end-to-end operation, when successfully performed, re-establishes the alimentary canal, generally without any diminution of its caliber, while the opening made in the lateral anastomosis as time goes on becomes contracted to such an extent that the feces can not pass.

Discarding the above operations as uncalled for in the great majority of cases, we now find the much-lauded Murphy button in full possession of the intestinal field. This method, which in every detail is superior to its vanquished brethren, has yet difficulties many and obvious, which

have long since sat in dumb appeal before the court of surgical jurisprudence.

Summoning a few of the principal ones before this august tribunal, we will examine them one by one. In the first place, when the bowel has been made ready for the operation, a purse-string suture is passed completely around each end of the severed gut, oftentimes proving a tedious task. One-half of the button is then passed into each end of the bowel, very frequently after repeated efforts, and the above-mentioned sutures tied snugly over them before the button is locked. The opening in the button is small, rendering it absolutely necessary to keep the contents of the bowels in a fluid state, otherwise the button becomes occluded, and this way may cause both the patient and the surgeon some discomfort. Frequently the button never comes away, and

FIG. 2.-Cylinder introduced into one end of the bowel, showing the invaginated portion.

laparotomy must be performed for its removal; as has occurred in the practices of Drs. Wyeth and Abbe, of New York City. In Dr. Wyeth's case he removed the button by abdominal section, after its having remained in the belly one hundred and twenty-seven days.

It is taught by most surgeons that if the condition of the patient will not justify a long operation, instead of doing a resection where strangulation and necrosis exist, the ends of the bowel must be drawn down and stitched to the abdominal wound, forming a fecal fistula, thereby rendering imperative a secondary operation.

I claim the above procedure is, in the majority of cases, unwise and unsurgical from the fact that with my technique an end-to-end anastomosis can be done in just as little time. With the above testimony before you, I beg leave to introduce my own method, known to my fellow-students as Johnson's end-to-end anastomosis of the intestines. The belly is opened under strict aseptic precautions, as in any case of

laparotomy, and the bowel drawn out through the wound, stripped, and tied off with strips of sterile gauze. The point at which the bowel is tied must be determined by the surgeon in each individual case; but in all cases the gauze should pass through the mesentery at least three inches from the bowel and be tied with a slip-knot. The peritoneal cavity is now well packed with pads of sterile gauze to absorb any. leakage occurring during the operation.

The section of gut to be removed is now cut out with the scissors along with a V-shaped piece of mesentery corresponding to the length of the bowel, and excised, and the ends of the bowel irrigated well with warm normal salt solution, and wiped dry with sterile gauze. The mesenteric junction of both ends of the bowel is securely closed, and a cylinder two inches in length (Fig. 1) (made of a potato, carrot, beet, parsnip, or in fact any vegetable from which a cylinder of the

MESENTERY.

FIG. 3.-Operation completed with cylinder in situ.

size of the gut to be operated upon can be made) is passed into one end of the severed bowel. As it enters the gut is sufficiently invaginated (Fig. 2) to bring peritoneum in contact with peritoneum of the opposite end of the bowel treated in a similar manner upon the other end of the cylinder. The cylinder is seized between the thumb and the index finger of the left hand and held steadily, while with an ordinary cambric needle, armed with a very fine silk thread, the two ends of the bowel are united by the introduction of a suture every one sixteenth of an inch, until coaptation is complete (Fig. 3). The sutures should only include the serous and muscular coats of the bowel, and are tied by the assistant as introduced, and they should in all cases be interrupted and cut very short. The opening in the mesentery may be closed either by continuous or interrupted sutures. Particular pains should be taken to close the mesenteric junction, as herein lies the great danger of leakage, sepsis, and death. The cylinder is left in situ (Fig. 3), as it does not interfere with union or the passage of the feces.