[Reprinted from the American Gynaecological and Obstetrical Journal 
for February, 1895.] 
THE VALUE OF PLASTIC WORK IN OPERATIONS 
INVOLVING THE PERITONAEUM* 
1/ 
By J. W. Long, M. I)., Richmond, Va., 
Professor of Gynaecology and Paediatry in the Medical College of Virginia ; Gynaecologist 
to the Hospital of the Medical College of Virginia; Fellow of the Southern Surgical 
and Gynaecological Association ; the American Association of Gynaecologists and Ob- 
stetricians ; Richmond Academy of Medicine; etc.; etc. 
The three essentials in successful abdominal work are (i) asepsis ; 
(2) hamostasis ; and (3) plastic work. We will consider only the last, 
noticing the first two merely as they are related to plastic work. I 
think, however, it can be clearly shown that plastic work contributes 
materially to both asepsis and haemostasis. 
In health the peritonaeum offers a smooth external surface, so that 
the viscera may move easily and without friction upon each other. 
This is due (1) to the anatomy of the peritonaeum, being covered as 
it is with endothelial cells ; and (2) to the serous secretion, which is 
just sufficient to keep the membrane moist. This membrane has two 
functions which stand out pre-eminently, (1) the absorption of any fluids 
that may be poured into its cavity ; (2) the formation of plastic lymph, 
producing adhesions. The first is, of course, an effort on the part of 
the peritonaeum to carry away deleterious matter. The second is also 
an effort of Nature, and under certain conditions is a life-saving pro- 
cess. Take for example a case of perforative appendicitis. The 
appendix is inflamed, ulceration begins from the inner side of the ap- 
pendix ; long before the perforation has reached the cavity of the peri- 
tonaeum, the peritonaeum throws out plastic material forming limiting 
adhesions, restraining and circumscribing the infectious matter, which 
* Read by title before the Southern Surgical and Gynaecological Association, at 
Charleston, S. C., November 20, 1894. 2 
J. IV. Long, M. D. 
is poured out through the perforation. The same is true of salpingitis. 
As soon as the tube is infected, the peritoneal coat of the fimbriated 
end begins to swell and soon closes the extremity of the tube, thus 
sealing the tube and preventing the infectious matter from reaching 
the peritonaeum by this channel. 
So then_ this plastic exudation should not be considered patho- 
logical, even though we grant that it never occurs in a state of health, 
but only when some morbid process is present. The abdominal sur- 
geon should ever bear this valuable and to me wonderful property of 
the peritonaeum in mind. 
But often this very conservative effort of Nature is perverted into 
a pathological condition, such for instance are the adhesions forming 
after abdominal section. These adhesions are hurtful in that they 
may produce (i) painful peristalsis; (2) constant pain; or even (3) 
ileus. So common is it for adhesions to form after an abdominal sec- 
Fig. i. 
tion, that the American Text-Book of Gyncecology says, that they always 
occur. 
The occurrence of adhesions was forcibly impressed on my mind 
in the case of a negro woman, from whom I removed an intraliga- 
mentous growth. After hulling out the tumor, the bed seemed clean 
and free from haemorrhage and I did not regard it necessary to close 
the parts. Four days after the operation I was compelled to reopen Value of Plastic Work in Operations Involving the Peritonaeum. 
3 
the abdomen, because of a leaking intestinal wound, when I found 
that coils of small intestine had fallen down into the cavity from 
which I had removed the tumor, and were densely adherent. Had I 
Fig. 2. 
taken the precaution to bring the edges of the ligamentous wound 
together, the intestines could not have got into the place. 
Adhesions sometimes form at a very limited point that is not covered 
by peritonaeum. I recall an instance of this kind in a case where I 
assisted my colleague, Dr. Johnston, to do a secondary abdominal 
section on a young lady, whose tubes and ovaries had been removed 
by another surgeon, because of epilepsy occurring at the time of her 
periods. The first operation had been done by a skillful surgeon, but 
her periods and the epileptic seizures continued and the woman's 
mind was rapidly becoming a blank. Dr. Johnston opened the abdo- 
men and found that the former operation had been a very clean and 
perfect one and the only pathological lesion to be found was the ad- 
hesion of two coils of intestines to the stump of the right tube. 
These he carefully freed, covered the abraded surfaces of the in- 
testine, touched the stump of the tube with the Paquelin cautery, 
and closed the abdomen without drainage. This case made a rapid 
and perfect recovery ; the periods ceasing, the seizures not returning, 
and her mind rapidly regaining its equilibrium. True this case is not 
an ordinary one ; the adhesions produced a reflex of a very exagger- 
ated nature, but it serves to illustrate the fact that a raw surface, ever f. W. Long, M. D. 
4 
so small, inside the peritoneal cavity, may cause adhesions, which are 
very detrimental to health. 
The ideal condition in which to leave the peritonaeum after an ab- 
dominal section is an unbroken endothelial surface. For it is to be re- 
membered that even an abrasion of the endothelial layer, invites the 
formation of adhesions. Much greater then is the danger of adhe- 
sions when the deeper coats, or even the entire thickness of the mem- 
brane, are destroyed. It is also worthy of note, that while two normal 
surfaces of peritonaeum can never unite, it requires that only one of 
the contiguous surfaces be abraded or injured to set up an adhesive 
inflammation. 
From these facts we learn two important lessons : (i) the readi- 
ness of the peritonaeum to form protective adhesions ; (2) the liability of 
the abraded or torn peritonaeum to cause adhesions that are harmful. 
The first of these is an effort of Nature, and is conservative, the 
second is pathological and is always deleterious. 
To prevent the pathological effects of the second, we utilize the 
protective influences of the first. This is done in many ways. For 
instance, no surgeon would close the abdomen and leave a rent in the 
parietal or visceral peritonaeum. He would carefully suture the edges 
of the rent together, knowing full well that if he did not adhesions of 
a dangerous, if not fatal, nature would result. 
In the now popular operation of supravaginal hysterectomy by the 
intraperitoneal method, one of the essential steps in the operation, is 
to carefully suture the peritoneal flaps together. 
In looking down into such a pelvis, we see only the bladder in 
front, the rectum behind, and the whole covered by one unbroken 
peritoneal membrane, save a trans- 
verse row of sutures, holding the 
flaps in position. 
In these cases when the peri- 
toneal flaps are short, I have even 
pulled down the posterior wall of 
the bladder to assist in covering 
the cervical stump. 
When removing densely adhe- 
rent appendages, it often happens 
that deeply abraded surfaces are 
exposed. It is imperative that 
they be dealt with in one of two ways-either they must be drained, 
or covered in such a manner as to prevent adhesions. 
Fig. 3. Value of Plastic IVork in Operations Involving the Peritonceum. 
5 
It has been my practice, as far as possible, to cover these abraded 
surfaces with healthy peritonaeum. This can not always be done. 
But the peritonaeum covering the lateral walls of the pelvis is rather 
loosely attached to the underlying tissues and may be made to cover 
adjacent surfaces. Of course, if the case is septic, no amount of plas- 
tic work, however beneficial, can do away with the necessity of drain- 
Fig. 4. 
Fig. 5. 
age. Not only do we lay bare these abraded surfaces in the removal 
of adherent pelvic masses, but sometimes the peritonaeum is stripped 
up from the walls of the pelvis and important structures, such as the 
iliac vessels and ureters are uncovered. 
A little plastic surgery will remedy both the abrasion and the tear. 
By means of a sharply curved needle, armed with a carrier a (hospital) 
No. 2 silk suture catches up the non-abraded edge of the rent, then 
skipping over the abraded surface, picks up the normal peritonaeum. 
'Phis suture may be continuous or interrupted. A reference to Figs. 
4 and 5 will show how the rent is closed and the abrasion covered by 
the same procedure. 
The principle advocated then, of covering all raw and torn surface 
with normal peritonaeum, whenever practicable, to prevent harmful 
adhesions is susceptible of wide application, but need not be further 
elaborated in this connection. 
Plastic work is of unquestionable value in wounds of the abdominal 
viscera, and in anastomotic operations. The principle is the same in 
both instances ; i. e., to bring peritonaeum against peritonaeum, when 
the plastic lymph quickly seals the wound in the viscus. 
It will be understood that I speak now only of the part which the 6 
J. W. Long, M. D. 
peritonaeum plays in these plastic operations, and do not consider the 
other very important and essential factor, namely approximation of 
the deeper structure of the viscera. Indeed, in some instances it is 
necessary to bring together only the peritoneal coat; as for example 
in cholecystenterostomy. 
Dr. Murphy has shown that a peritoneal adhesion one line wide is 
all sufficient to maintain the anastomosis. 
But the value of this procedure for wounds and anastomoses is so 
obvious that it is trespassing on your time to dwell longer on this 
point. 
As an hcemostatic measure, plastic procedures are of undoubted 
value. All raw or torn surfaces bleed or ooze, more or less. To 
cover such surfaces with normal peritonaeum, is to restrain the bleed- 
ing and prdtect the abdominal cavity from the presence of serum. 
The instances already cited when discussing adhesions, might also be 
used to illustrate this point ; therefore I will notice only one other. 
In vaginal hysterectomy, as soon as Douglas' cul-de-sac is opened, it 
is important that the serosa, and vaginal mucosa be sutured together 
in order to restrain all bleeding. The same should be done in front 
when the utero-vesical fold is opened. When the operation is com- 
pleted properly, there is no raw surface left uncovered, hence no 
haemorrhage can occur. It must not be understood that under any 
circumstances is it intended for plastic work to take the place of 
thoroughly ligating all bleeding vessels. 
Plastic work is also of great service as an aseptic measure, because 
it has been clearly shown that pathogenic germs increase more rapidly 
when the peritonaeum is unable to absorb the liquids which are poured 
into its cavity. In other words, they flourish more abundantly in a 
moist than in a dry field. Hence if by plastic work we leave only 
normal peritoneal surfaces in the abdominal cavity, we not only have 
the best possible conditions for absorption, but we lessen the amount 
of the haemorrhage and serous exudation and rob any infectious 
germs, which by chance may have found their way into the peritoneal 
cavity, of the pabulum that is conducive to their development. 
We may sum up the ideas which have been so imperfectly pre- 
sented in this paper, by saying that plastic work is of value in peri- 
toneal operations : 
1. Because it prevents pathological adhesions. 
2. Because it induces protective adhesions. 
3. Because it is an haemostatic measure. 
4. Because it promotes asepsis.