A Case of Gastrostomy performed 
according to Kader’s Method. 
BY 
WILLY MEYEE, M. D., 
Professor of Surgery at the New York Post-Graduate Medical 
School and Hospital; Attending Surgeon to the German 
Hospital and to the New York Skin and Cancer 
Hospital; Consulting Surgeon to the 
New York Infirmary. 
Ncto Yorfe J&etucal journal 
REPRINTED PROM THE 
for November 7, 1596. Reprinted from the New York Medical Journal 
for November 7, 1896. 
A CASE OF GASTROSTOMY 
PERFORMED ACCORDING TO KADER’S METHOD. 
WILLY MEYER, M. D., 
PROFESSOR OF SURGERY 
AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ? 
ATTENDING SURGEON TO THE GERMAN HOSPITAL 
AND TO THE NEW YORK SKIN AND CANCER HOSPITAL ; 
CONSULTING SURGEON TO THE NEW YORK INFIRMARY. 
In No. 28 of the Centralblait filr Chirurgie, July 11, 
1896, Dr. Bronislaw Kader, assistant to the surgical 
clinic of Professor Mikulicz, of Breslau, published an 
interesting article, A Contribution to the Technics of 
Gastrostomy, in which he describes a new method of 
his own which is a modification of the well-known Wit- 
zeFs method.* 
He states that in January, 1895, he had to establish 
a gastric fistula in a case of cicatricial stricture of the 
oesophagus and of the pylorus. The stomach was ex- 
ceedingly small, and movable to such a slight extent only 
that most of the formerly tried methods of gastrostomy 
could not be made use of. Also that of Witzel—which 
so far had been done by Professor Mikulicz almost ex- 
clusively in cases which needed gastrostomy—could not 
* Centralblatt fur Chirurgie, 1891, No. 32, p. 601. 
Copyright, 1896, by D. Appleton and Company. 2 
GASTROSTOMY ACCORDING TO KADER’S METHOD. 
be carried out, because a rather long incision had been 
made through the anterior wall of the stomach for 
digital exploration of the interior of the latter and of 
the region of the pylorus. Kader therefore modified 
Witzel’s method, and found that the functional result 
in this modification was Just as perfect as that of the 
former, while the technics—which differed rather mate- 
rially from Witz el’s method—presented a number of ad- 
vantages, viz.: it can be done in all cases, even the 
most difficult ones; it can be carried out faster and in 
a simpler manner, and is feasible even in such cases 
where the character of the disease necessitated, for digi- 
tal exploration of the interior of the stomach, a primary 
incision of the anterior gastric wall, and a longer one 
than we need if for gastrostomy.* 
For these reasons Witzel’s method has lately been 
substituted in the Breslau Clinic by that of Kader. 
The operation is carried out in the following man- 
ner: An incision three by four inches (seven by ten cen- 
timetres) long is made, penetrating skin and fascia, and 
parallel with the border of the left ribs, one and a half 
by two fingers’ width distant from the same. (In a foot- 
note, Kader states that the simpler vertical incision 
might also be used. I think this should be done in every 
instance.) A blunt division of the left rectus muscle is 
made for a distance of about two and a half by three 
inches (six to eight centimetres). The posterior sheath 
of the rectus muscle and the peritonseum are incised. 
As will be seen, this is the way von Hacker pro- 
posed for penetrating the abdominal wall.f Kow a 
* I want to state here that I fail to see any reason why this latter 
procedure could not be done in Witzel’s operation as well. 
\ Wien. med. WochenschrlBB6, 31 and 32. GASTROSTOMY ACCORDING TO KADER’S METHOD. 
small fold of the stomach is pulled forward in the 
usual way, with the help of the fingers or of the 
forceps, or of two slings of silk which have pri- 
marily been put through the serous and muscular 
coats of its wall, the wound meanwhile being held 
apart by blunt retractors. If the stomach is movable, 
the fold is, of course, drawn in front of the abdominal 
wall, the surrounding field being packed with aseptic 
gauze in order to do the following steps of the operation 
extraperitoneally. Then a small incision is primarily 
made between the two slings, and a drainage-tube of 
about a pencil’s size introduced into the stomach for a 
distance of about two by two and a half inches (five by 
six centimetres). The few spurting arteries of the gas- 
tric wall are, as usually, ligated with fine silk (or cat- 
gut). So far, the procedure is the same as in WitzeFs 
method. The drainage-tube is at once fastened to the 
side of the stomach wound by a catgut stitch (Fig. 1 ,a).* 
Then two Lembert sutures (Fig. 1, h) are put on either 
side of the tube in such a way that they catch and unite 
a portion of the surface of the stomach of about half an 
inch (one centimetre) width, leaving between a groove 
of three fourths of an inch (two centimetres) width (see 
Fig. 1), The two sutures on either side are about half an 
inch (one by one and a half centimetre) apart. By tying 
these sutures (“ deep occlusion-sutures ”), which, of 
course, catch the serosa and the underlying muscularis, 
two longitudinal folds are formed (Fig. 1, c), which 
turn inward the wall of the stomach in the immediate 
neighborhood of the tube and thus surround the latter 
in the shape of a narrow funnel (Fig. 1, d). Thus the 
drainage-tube is situated in a canal lined by serous mem- 
* The cuts reproduce those of Kader’s article. 4 
GASTROSTOMY ACCORDING TO KADER’S METHOD. 
brane which does not pass the gastric wall obliquely, 
but enters it in a perpendicular, straight way. In order 
to lengthen this canal, two more folds of the stomach 
Fig. 1. 
wall are stitched on top of the first ones (Fig. 2, c 1), in 
the same manner and direction as described before, again 
with the help of four sutures, two on either side of 
the tube (“ superficial occlusion sutures,” Fig. 2, h1). 
The outer threads of these sutures * are not cut short, 
but left long in order to have a good hold on the stom- 
ach during the further manipulations. (This I learned 
by personal experience to be an important point.) Flow 
* I have marked them in the cuts, Fig. 2 and Fig. 3, with X. GASTROSTOMY ACCORDING TO KADER’S METHOD. 
5 
the entire area of the stomach is stitched to the edges 
of the peritoneal wound and that of the posterior sheath 
of the rectus muscle, thus rendering the operating field 
extraperitoneal. Then the bluntly divided rectus mus- 
cle is drawn together with the help of a few stitches, 
the anterior sheath of the rectus muscle sutured, and the 
skin closed on either side of the tube by stitches. 
Fig. 2. 
If wanted, feeding through the tube may he begun 
at once. 
In establishing the fistula, one has, of course, to 
look out that those sutures which are put in nearest the 
drainage-tube are put in neither too far away nor too 
near to the same. The stomach wall must surround 
the tube in a rather gentle tension. If the stomach can 6 
GASTROSTOMY ACCORDING TO RADER’S METHOD. 
not be well pulled forward into the wound, Kader 
advises that the deep occlusion sutures be put in pri- 
marily, and that with the help of these the stomach 
be drawn up against the abdominal wall in order to 
close off the peritoneal cavity when the incision into 
the stomach is made. 
In a case of malignant stricture of the oesophagus 
very near the cardia, in which I lately performed Kadeffs 
gastrostomy myself, even this was not well feasible; I 
therefore had to carefully surround the held of opera- 
tion, inside of the abdomen, with aseptic gauze sponges, 
and to open the stomach within the abdominal cavity. 
As the stomach was entirely empty, no juice escaped. 
Kader mentions that the folds (Fig. 1, c, and Fig. 
2, c 1) can be made in a perpendicular as well as in a 
transverse direction. The former is preferable in cases 
where we want to establish a permanent fistula, as in 
cancerous stricture of the oesophagus; the latter in 
benign, cicatricial ones. The canal has a greater mo- 
bility in the direction toward the cardia if the folds 
are put in the transverse direction. This mobility will 
enable us to reach the cardia easier, and thus more 
readily carry out retrograde dilatation, etc. 
If it should have become necessary to open the stom- 
ach by a larger incision primarily, in order to explore its 
interior with the finger, this wound is closed by Lem- 
bert’s sutures up to the spot where the tube is made to 
enter. Thence the operation is carried out as described 
above. 
It is of the greatest importance to have the field of 
operation on the stomach well lined with peritonaeum— 
in other words, to fix the stomach firmly to the parietal 
peritonaeum. Kader seems to do this, according to his GASTROSTOMY ACCORDING TO KADER’S METHOD. 
7 
diagram (Fig. 3, e1), by sutures where the thread passes 
through the posterior sheath of the rectus muscle and 
peritonaeum on the one side, then through the stomach 
wall, and again through the peritonaeum and the poste- 
rior sheath of the rectus on the other side. In the case 
Fig. 3. 
in which I lately operated according to Kader’s method, 
I did this act of the operation as I have proposed in my 
article on Eecent Methods of Gastrostomy for Stricture 
of the CEsophagus (published in the American Journal 
of the Medical Sciences, October, 1894)—viz., by passing 8 
GASTROSTOMY ACCORDING TO KaDER’S METHOD. 
a silkworm-gut suture on either end of the field of opera- 
tion through the entire abdominal wall, grasping on its 
way the stomach wall (Fig. 3, e). These sutures are tied 
only at the end of the operation, when the skin wound is 
closed with silkworm gat. They hold the stomach 
firmly up to the abdominal parietes. I then also stitched 
the fascia, plus peritonaeum, around the line e e (Fig. 3) 
with a running catgut suture. 
With reference to the after-treatment not much can 
he said. From about the third to the fifth day after the 
operation the catgut stitch which fastened the tube to 
the side of the small stomach wound (Fig. 1, a) will 
have been reabsorbed. Then the tube must he pierced 
by a safety pin in front of the dressings and attached 
to the latter (Kader), or better, I believe, as I have ad- 
vised (loc. cit.), by slipping over the tube down to the 
abdominal wall a short piece of the next larger size of 
tubing armed with two safety pins. A piece of gauze, 
partially incised, is pushed underneath the pins, another 
one with a small centre hole on top. Both are held in 
place by the rubber adhesive plaster straps, as used for 
laparotomy, or by a square piece of muslin with a small 
centre hole and one or two long pieces of tape on either 
side, which pass around the body and are tied by the 
patient in front. Once a week, or oftener if desired, the 
tube is changed to be cleansed. It must be remembered 
that it should not he left out for any length of time. 
The fistula established according to Kader’s method, 
as well as that of Witzel’s, “ closes spontaneously,” or 
after superficial cauterization, as soon as the tube is per- 
manently removed. 
In the way just described, the operation has been 
carried out in Mikulicz’s clinic ten times (eight times GASTROSTOMY ACCORDING TO KADER’S METHOD. 
9 
by Dr. Kader and twice by Professor Mikulicz), in five 
patients for cancerous and in four for cicatricial stric- 
ture of the oesophagus; in one patient the latter was 
compressed and impassable in consequence of a peri- 
chondritis laryngis due to specific disease. The young- 
est patients were five and six years old. Three times the 
operation was done, on account of the low condition of 
the patient, under local cocaine anassthesia, after 
SchleiclTs method. All ten patients recovered without 
any annoying accident. The elder were allowed to get up 
on the second, and even on the first day after the opera- 
tion. One can rely absolutely on the fixation sutures 
which hold the stomach firmly attached to the anterior 
abdominal wall. 
The functional result was ideal in every case. Even 
when the tube was removed there was no leakage what- 
ever, no matter how the patients turned or what posi- 
tion they assumed. Kader thinks that a number of 
causes combine to produce this satisfactory result. The 
serous surfaces, which are sutured together, rapidly be- 
come adherent to each other and grasp the rubber tube 
pretty snugly. Furthermore, the position of the inner 
opening of the fistula, at the tip of a compressible fun- 
nel, and the pronounced folds of the mucous membrane 
which run toward the entrance of this funnel (see Fig. 
4) prevent regurgitation of the gastric contents. Also 
the sphincterlike action of the rectus muscle, surround- 
ing the tube on its way to the surface of the abdomen, 
deserves mention as an agent in rendering the fistula 
water-tight. At last, it is most probable that the fibres 
of the muscularis of the stomach, which surround the 
fistula in KadeEs method in a double layer, act like a 
sphincter. Kader emphasizes that these same causes 10 
GASTROSTOMY ACCORDING TO KADER’S METHOD. 
are underlying the good functional results obtained by 
Witzel’s method; in other words, that it is not the ob- 
lique penetration of the fistula through the gastric wall, 
Fig. 4. 
which makes it water-tight. As frequently observed in 
Mikulicz’s clinic, the oblique canal later assumes a 
straighter direction, sometimes as early as three weeks 
after the operation. Yet the patency of the fistula 
has always remained perfect.* 
On reading Kader’s article I was struck by the sim- 
plicity of the procedure, and at once resolved to carry 
* The same phenomenon was seen in one of my patients operated 
upon according to Witzel’s method (American Journal of the Medical 
Sciences, loc. cit.). GASTROSTOMY ACCORDING TO KADER’S METHOD. 
it out in a patient, Mr. J. W., aged fifty-four years, on 
whom I had to do gastrostomy the following day for 
increasing cancerous stricture of the oesophagus, from 
which he had been suffering since November, 1895. 
The operation was performed on July 31st in the pres- 
ence of Dr. A. Hadden of this city, who had, together 
Avith Dr. Max Einhorn, treated the patient before. It 
was carried out strictly in accordance with Kader’s di- 
rections, with the exceptions mentioned above—namely, 
that the stomach was held up to the abdominal parietes 
on either end of the field of operation by a silkworm- 
gut stitch which penetrated the entire abdominal wall, 
and that the field of operation was lined by peritonaeum 
and fascia by means of a running suture. The external 
wound was entirely closed by stitches, layer by layer, up 
to the tube. The wound healed by primary union 
throughout and has been water-tight from the beginning. 
The patient was up on the fourth day after the tube had 
been inserted, and left the private hospital just one 
week after the operation. To-day, two weeks later, the 
fistula proves to he just as water-tight as it was on the 
first day after the operation; not a drop regurgitates 
alongside the tube or through the canal when the tube 
is removed. The patient is gaining in weight.* 
Since publishing my article on Recent Methods of 
Gastrostomy for Stricture of the (Esophagus (loc. cit.), 
where I reported fourteen cases of this operation, done 
by myself, in all (viz., two according to the old Fen- 
* The patient was presented to the Scientific Society of German 
Physicians on September 25th. The functional result of the operation 
is perfect. It was interesting to me to watch the canal immediately 
after the removal of the tube. If the patient had been fed just before, 
a certain amount of the contents of the stomach oozed out. Meanwhile 
the canal in its deeper portion slowly contracted (by active contraction 
of the muscular layer of the gastric wall?) until the opposite walls 
came into contact. Then all leakage ceased, no matter whether the 
patient coughed or pressed or took any desired posture. 12 
GASTROSTOMY ACCORDING TO KADER’S METHOD. 
ger’s, six to von Hacker’s, and three to Witzel’s and 
Ssabanejew-Frank’s method each), I have done gastros- 
tomy in nine more patients—four times according to 
yon Hacker and five times according to Ssabanejew- 
Frank—twenty-three times in all. None of the last nine 
patients died in consequence of the operation as such. 
Twice the operation (von Hacker) had to be done under 
cocaine, as the patient’s condition did not permit of 
general anaesthesia. 
So far as the functional result of the operation is 
concerned, von Hacker’s method has given me a uni- 
formly good one. Only now and then the fistula com- 
menced leaking slightly in the course of time. Then 
the tube had to be replaced by one of a larger size. 
I should still recommend von Hacker’s operation as the 
one which can be carried out in the easiest way, taxes 
the patient’s strength the least, and promises, if done 
properly, a lasting good functional result. 
I should have resorted to Witzel’s operation oftener— 
the safest and best one so far as the question of avoiding 
subsequent leakage is concerned—if one could, in this 
method, enter the abdominal cavity by bluntly dividing 
the left rectus muscle. I greatly like this latter pro- 
cedure when establishing a gastric fistula. Wherever, 
during this first part of the operation, the handle of the 
scalpel finds a resistance in separating the muscular 
fibres, a transversely running blood-vessel is met with. 
Two clamps are applied, and the vessel divided between 
them. Thus the posterior sheath of this muscle and the 
peritonamm are rapidly reached, without any blood hav- 
ing been lost, and that in a most easy and convenient 
way, which besides proves to be of great value to the pa- 
tient in the future. For these reasons I have lately com- GASTROSTOMY ACCORDING TO KADER’S METHOD. 
13 
bined von Hacker’s and Ssabanejew-Frank’s methods. 
But I experienced, especially in my last case of this kind, 
done on July 13, 1896, that the fistula leaked in the 
beginning, especially right after feeding. Here a com- 
paratively short cone of the anterior wall of the stom- 
ach could be raised only, so that the small second wound 
had to be made below, instead of above, the border of the 
left ribs. In my next case I shall twist the cone for 
one hundred and eighty degrees—according to Ger- 
suny’s procedure on the female urethra for incontinence 
of the bladder—and then, after having pulled it under- 
neath the bluntly undermined bridge of skin, stitch the 
opening of the stomach to the borders of the second 
small wound. Helferich, of Greifswald, has lately done 
this with a most satisfactory result. I should do it even 
if no difficulty was encountered in raising a sufficiently 
long cone of the anterior stomach wall. 
WitzeFs operation requires a more or less oblique 
incision and the blunt division of at least the external 
and internal oblique muscles. In very muscular pa- 
tients, the rectus and transversalis muscles may be en- 
countered only; in others, a layer of three muscles may 
have to be separated and held apart. This sometimes 
proves to be a rather tedious work—certainly more 
tedious than to divide bluntly the left rectus muscle 
alone—and may require the help of an additional assist- 
ant. The lining of the operating field on the stomach 
with peritonaeum is sometimes in WitzeFs operation also 
not a very handy procedure, especially in robust indi- 
viduals. 
Kader’s operation, however, combines the advan- 
tages of von Hackers and of WitzeFs method in a most 
convenient and ingenious way, and makes the gastric 14: 
GASTROSTOMY ACCORDING TO KADER’S METHOD. 
fistula water-tight by entering the stomach in a direct 
perpendicular line, whereas Witzel tried to obtain the 
same result in a rather roundabout (oblique) way. 
I therefore believe that Kader’s method of gastros- 
tomy for stricture of the oesophagus will he much liked 
by surgeons and he rapidly introduced into the surgery 
of the stomach everywhere. The New York Medical Journal 
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