Page images
PDF
EPUB

The anesthetic should be one that gives complete relaxation. In this respect spinal anesthesia is ideal. In the smaller hernias local field block is quite satisfactory.

At operation there should be a wide excision of the skin scar, keeping in mind the fact that frequently no peritoneal covering to the viscera exists, the hernial contents lying immediately beneath a very thin cicatrix in the skin. It is advisable to develop the incision through fairly normal tissues until the normal aponeurosis is identified. Only then is it safe to proceed toward the abnormal scarred tissues of the hernial area, working carefully and being constantly on the alert for pockets in which a loop of gut may be adherent.

Opinion is divided as to the advisability of opening the sac and breaking up the peritoneal adhesions. I personally believe that the adhesions in the immediate vicinity of the hernial ring should be broken up and the peritoneum closed as a single layer whenever possible.

Acute intestinal obstruction is not a common complication; but, when present, resection of the bowel should never be done unless it is hopelessly diseased, as it markedly increases the operative mortality rate.

If the operation of Gallie and Lemesurier (living fascial sutures) has been selected as the method of repair, the muscles, fascia, and aponeurosis are not dissected out into their various layers but are closed as a single layer by running sutures of fascia lata approximately 4 inch (6 cm.) in width. A second row of sutures placed over the first and going back about 1 inch (2.5 cm.) from the edge of the defect may be used when the opening is large and there is apt to be considerable tension on the suture line.

In many of the giant hernias there has been such severe damage to the abdominal wall that it is impossible to completely close the opening, and in others it is possible to do so only with such marked increase in the intra-abdominal pressure as to endanger the life of the patient. It is this type of patient that demands one of the fascial-patch operations.

The outstanding operation of this type is that described by Gallie in 1932. The patch is taken from the fascia lata and greatly resembles the old-fashioned, many-tailed, abdominal binder. If the hernial defect is more than 31⁄2 inches (8.75 cm.) in length, it is necessary to cut two patches from the fascia lata, laying them side by side across the opening. As a rule, two patches of fascia 5 by 31⁄2 inches (12.5 by 8.75 cm.) can be obtained from the lateral aspect of a single thigh. After the hernial ring has been dissected out, the peritoneum is pushed back from the edge of the opening for 1⁄2 inch (1.25 cm.) or more, so that the needles that have been threaded on the ends of the patch may be passed from within outward through the edge of the ring without entering the peritoneal cavity. At the ends of the

hernial opening, special precaution is taken to weave the tails into the edge of the ring so as to prevent a protrusion over the end of the fascial sheet. When all the tails have been drawn through the abdominal wall they are then tied together, each to its opposite fellow, and the knots oversewn with catgut sutures. A small drain may be placed beneath the skin to remove any serum that might collect; however, it has been my observation that serum is less frequent in hernia incisions where fascial sutures have been used than with the other types of suture material.

There will be an occasional patient whose general physical condition is such that the dangers from any surgical procedure will outweigh the good that might be derived from a successful hernial repair. One must then be content with providing the patient with a wellfitting abdominal support.

CONCLUSIONS

1. In the production of ventral hernia the surgeon's knife plays a greater role than other types of traumatism.

2. Wound infection and atrophy of the abdominal parietes are the two chief causes of hernia in post-laparotomized patients.

3. In many cases infection is inherent in the nature of the condition for which surgery is being undertaken, and the development of a ventral hernia is of only secondary importance.

4. The incidence of post-operative ventral hernia has been estimated at anywhere from 1 to 9 percent in clean cases, and from 15 to 31 percent in infected laparotomy wounds.

5. Symptoms of chronic intestinal obstruction are frequently associated with ventral hernia.

6. Acute intestinal obstruction is an uncommon, but serious, complication of ventral hernia.

7. Recurrence following repair of ventral hernia has been reported in from 14 to 40 percent of patients.

8. This high-recurrence rate makes prevention of the utmost importance.

9. Attention to the pre-operative preparation of patients, proper choice of incisions, reduction of drainage to an absolute minimum, the careful closure of operative wounds, and an intelligent, watchful, post-operative regime will prevent many ventral hernias.

10. Primary surgical treatment (debridement) of war and industrial wounds of the abdominal wall will prevent hernias in many patients. 11. The large number of operative procedures described for the cure of ventral hernia leads one to the conclusion that none are entirely satisfactory.

12. An attempt has been made to group the various operations described in the literature.

[graphic]

IN THE GARDEN OF THE AMERICAN EMBASSY IN BRUSSELS AMBASSADOR MORRIS BESTOWING THE CROSS AND HONORARY MEMBERSHIP OF THE ASSOCIATION OF MILITARY SURGEONS OF THE UNITED STATES OF AMERICA ON LIEUTENANT GENERAL DECLERCQ, ASSISTED BY MAJOR GENERAL PATTERSON, CHAIRMAN OF THE DELEGATION OF THE UNITED STATES. OTHER MEMBERS OF THE DELEGATION AND MEMBERS OF THE EMBASSY STAFF WERE PRESENT. THE CROSS AND HONORARY MEMBERSHIP OF THE ASSOCIATION OF MILITARY SURGEONS OF THE UNITED STATES WAS BESTOWED ON LIEUTENANT GENERAL DERACHE OF THE BELGIAN ARMY MEDICAL CORPS in absentia, BECAUSE OF THE SERIOUS ILLNESS WHICH PREVENTED HIS BEING PRESENT.

13. Fundamentally, there is no difference in the treatment of hernias secondary to laparotomy and those due to other forms of trauma, such as gunshot wounds.

14. Repair of ventral hernia, for the greater part, is chiefly a matter of suture material.

15. Catgut, silk, linen, and silver-wire sutures have all proven unsatisfactory.

16. The operations that make use of living fascia, either as sutures, or patch grafts, give the highest percentage of cures.

17. The iliotibial band of the fascia lata affords an excellent and plentiful supply of living fascia that can be utilized for these purposes.

Gilorteanu; Costescu (Rumania)

In their joint report on the "Sequelae of Abdominal Injuries", Major I. Gilorteanu and Captain P. Costescu of the Rumanian Army Medical Service stated that the sequelae of abdominal injuries in war are extremely rare, because of the high immediate mortality of such injuries. But having had occasion lately to review some 22,680 cases with the purpose of ascertaining the percentage of disability, the writers have been able to pick out all the old cases of abdominal wounds that have had sequelae. Their number reaches only 32. However, the data received afford information concerning these sequelae.

It is beyond doubt that these statistics are not complete, because the review is not yet terminated; and it is probable that it is precisely the wounded with grave sequelae who have not yet presented themselves. Abdominal wounds number 4.51 percent of the total of all war wounds, according to Clavelin. They have a very serious prognosis, and there are few such patients left to suffer from sequelae. The wounding agents used during the World War were, in the majority of cases, bursting shells, grenades, and mortar projectiles of great dimensions and of exceptional power of destruction, producing lesions so serious that they were beyond all the resources of surgery.

The prognosis for abdominal wounds has been all the worse, first, because the wounded did not reach the surgeon until well beyond the first eight hours during which the surgeon's help has a chance of success; and, then, by the unfavorable conditions under which such aid could be given. The immediate mortality was very great. Beyond the immediate danger and their exceptional gravity, these wounds may have far-reaching consequences, which may be revealed long after the wound has been treated-long after the surgical help is received. These sequelae appear in many different ways: From the simple inoffensive cicatrix of the abdominal walls to uncontrollable eventration, and artificial anus, or a grave intestinal occlusion, infirmities which transform the patient into a veritable invalid or which necessitate a serious surgical operation with a very grave prognosis.

« ՆախորդըՇարունակել »