LUMBAR VERSUS ILIAC COLOTOMY. 
BY 
JOHN B. BEAVER, M.D., 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC ; DEMONSTRATOR OF ANATOMY AND 
LECTURER UPON SURGICAL ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA ; 
ATTENDING SURGEON TO THE PHILADELPHIA, GERMAN, ST. AGNES’S, 
AND ST. MARY’S HOSPITALS. 
REPRINTED FROM THE TRANSACTIONS OF 
THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
FEBRUARY 25, 1891. Reprinted from the Transactions of the Philadelphia County Medical Society, February 25,1891. 
LUMBAR VERSUS ILIAC COLOTOMY. 
By JOHN B. DEAVER, M.D., 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC; DEMONSTRATOR OF ANATOMY 
AND LECTURER UPON SURGICAL ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA; 
ATTENDING SURGEON TO THE PHILADELPHIA, GERMAN, ST. AGNES’S, 
and st. mary’s hospitals. 
The subject which appeals to every surgeon whose lot it is to see 
many cases of carcinomatous disease of the rectum, is that of colotomy. 
My object in writing a paper on this topic is to record the result of 
my experience in the two operations—lumbar and iliac, not inguinal, 
as it is frequently called; to advocate the establishment of an arti- 
ficial anus early in the disease, when it is not feasible to remove 
the involved portion of the bowel; to speak of the indications for 
the operation; and of operative procedures other than colotomy, for 
malignant disease of the large intestine elsewhere than in the rectum. 
Having performed both lumbar and iliac colotomy, I am convinced 
that, in the majority of cases, the lumbar operation is preferable, as 
well as the most logical, for the following reasons : 
1. Notwithstanding the opening of the peritoneal cavity is now a 
factor of comparatively little importance when deciding between what 
shall be an intra- or an extra-peritoneal operation, I believe that, 
when the same end can be accomplished without opening the peri- 
toneum, the patient should be given the benefit of it. We must admit 
that an additional risk, be it ever so small, is coupled with an intra- 
peritoneal operation. 
2. Regarding simplicity. The essential element of success in any 
operation is a correct knowledge of the surgical anatomy of the part. 
The lumbar operation is as simple as the iliac, especially when the 
intestines are greatly distended, as they are apt to be in the advanced 
stages of the disease, when symptoms of obstruction are pronounced 
and when acute obstruction supervenes upon chronic. In opening the 
peritoneal cavity where the abdomen is distended, the protrusion of 2 
BEAVER, 
the small intestine through the wound complicates the operation. 
When the abdomen is distended, the lumbar operation is simplified by 
the bulging of the colon into the wound, thus making it more acces- 
sible. The advocates of the iliac operation claim that the additional 
advantages gained by opening the peritoneal cavity, providing the 
disease has not extended too far, are: to verify the diagnosis, to de- 
termine definitely the extent of the disease, to resect and reestablish 
the continuity of the canal. I do not regard the diagnosis in car- 
cinomatous disease of the rectum or the sigmoid flexure, assuming the 
form of a growth or a stricture, with symptoms both local and 
general, together with the history of the case and what can be learned 
by an examination of the abdomen and of the rectum (if need be, 
assisted by anaesthesia), at all difficult. Where the sigmoid alone is 
involved, the additional comfort gained by a resection would not 
warrant the patient assuming the risk consequent upon this operation, 
in comparison to that of establishing an artificial anus through the 
loin. 
The advocates of the iliac operation, again, produce the following 
arguments in its favor, namely: 
1. The impossibility of opening the small for the large intestine. 
In answer to this I can say, this mistake cannot occur in the lumbar 
operation unless the peritoneum is opened, which should not occur to 
a careful surgeon, non-interference with the peritoneal cavity being 
the important factor in the lumbar operation. Should the surgeon be 
unfortunate and open the peritoneal cavity in the lumbar operation, 
mistaking the small for the large intestine would be a gross anatomical 
error. The presence of one or more epiploic appendices tells posi- 
tively that it is the large intestine, these never being present as con- 
stituents of the small intestine. Again, the arrangement of the 
longitudinal muscular fibres of the large intestine into three separate 
bands, and the sacculated condition of the large intestine where both 
are not obscured by distention of the gut, assist in deciding the ques- 
tion. The small intestine may be met with so distended as to equal 
or exceed in size that of the circumference of the large; under such 
circumstances, the question of difference would be still more difficult 
for the surgeon not familiar with the anatomical peculiarities of both. 
The percentage of cases in which the descending colon does not hold 
its normal position to the abdominal walls posteriorly is so very small 
as, in my mind, not to enter into the question of deciding between the 
two operations. In the large number of bodies I have seen dissected 
in the anatomical rooms of the University of Pennsylvania, I have yet LUMBAR VERSUS ILIAC COLOTOMY. 
3 
to meet with a single case of pronounced anomalous arrangement; yet, 
I would not be understood as disputing the fact. Mr. T. Bryant, 
having operated in 170 cases, in but one of which he found it necessary 
to prolong his incision forward to find the colon at the brim of the 
pelvis, is the best argument to offset that set forth by the supporters 
of the iliac procedure. 
2. The position of the anus in the iliac operation is claimed to be a 
more convenient one for the patient to keep clean, as well as for the 
adjustment of the necessary pad which has to be constantly worn. I 
admit that an artificial anus in the abdominal walls anteriorly can be 
kept clean more conveniently by the patient than one in the loin; 
but the former situation, owing to the recession of the abdominal 
walls in certain positions assumed, allows the pad to shift. This is 
not the case in the loin, as the latter offers a more fixed and stationary 
point to retain the pad. 
3. Those who prefer the iliac operation claim that, owing to the 
meso-sigmoid being longer than the descending meso-colon, it renders 
the stitching of the bowel to the edges of the wound easier; also, that 
there is less tendency to prolapse of the gut following this than the 
lumbar operation. I confess that the long sigmoid meso-colon will 
permit of the bowel being drawn up much further than will the com- 
paratively short descending meso-colon. This offers, however, no 
advantage over the lumbar operation, as the length of the descending 
meso-colon is such as to allow the surgeon to bring the bowel up far 
enough to suture it to the edges of the wound of the abdominal walls, 
before or after it is opened, without any difficulty. In the case of a 
very fat subject, where the abdominal walls are flaccid, the last stages 
of the lumbar would be somewhat more difficult than that of the 
iliac operation. 
The formation of the spur, the barrier to the passage of the con- 
tents of the intestine from the upper into the lower opening, is claimed 
as being more pronounced after the iliac than the lumbar operation. 
This has not been so in my experience; on the contrary, I have 
been very much disappointed with the iliac operation in this respect. 
True, I have only performed two of the iliac operations; in both of 
these the patients were greatly annoyed by the collection of feces in 
the rectum above the seat of the trouble, and the consequent rectal 
tenesmus excited by the same. In my lumbar colotomies, by follow- 
ing the plan adopted by Mr. Bryant, namely: Having exposed the 
descending oolon by an incision carried in the line of the normal 
crease situated about midway in the costo-iliac space—the structures 4 
DE AVER, 
divided being the skin, the superficial and deep fascia, the posterior 
border of the external oblique, the anterior border of the latissimus 
dorsi, the lumbar fascia with the posterior borders of the internal 
oblique and transversalis muscles, and the anterior border of the 
quadratus lumborum and the fat covering the posterior surface of the 
bowel, which should be separated by the fingers—it is grasped at the 
site of the posterior longitudinal muscular band, rotated well forward 
on its longitudinal axis, brought into the wound, and there fixed. 
Operating in the above manner, I have formed a most excellent spur, 
serving its purpose very satisfactorily to the patient as well as to 
myself. I would restrict the iliac operation to that class of cases 
where the upper portion of the sigmoid flexure is not involved, and 
where it is done first as an exploratory measure—not in a diagnostic 
sense, but for the purpose of determining whether resection is justifi- 
able, when, if it be impossible, the operation is completed as an iliac 
colotomy. In the two iliac colotomies that I have performed, the 
cases not being urgent, I divided each operation into two stages; the 
first consisted in fixing the bowel in the wound (colorraphy), and the 
second in opening the bowel at the end of seventy-two hours. It is 
not necessary to give an anaesthetic when the bowel is opened, it 
being almost painless. I follow this course in the lumbar operations 
as well, when the urgency of the cases does not demand an immediate 
opening. 
Indications for the operation : Carcinoma of the rectum, either in 
the form of a growth or a stricture, too high to render the removal 
through the perineum or back by excising the coccyx, and, perhaps, 
one or two of the lower segments of the sacrum, or through both the 
perineum and the back. 
Stricture of the terminal part of the sigmoid flexure and of the 
upper part of the rectum with symptoms of obstruction, too high to 
treat successfully by dilatation, divulsion, or division. 
Incurable cases of recto-vaginal or recto-vesical fistula. Extensive 
and otherwise incurable cases of ulceration of the rectum, making life 
a burden to the patient. 
Imperforate anus, where operation through the perineum and back 
proves of no avail. 
Irremovable growths of the pelvis, causing obstruction by making 
pressure upon the rectum. In this connection, I will make mention 
of a suprapubic cystotomy that had to be done by a colleague in one 
of our hospitals for retention of urine, occasioned by pressure of such LUMBAR VERSUS ILIAC COLOTOMY. 
5 
a growth against the base of the bladder. Here it was only possible 
to pass a catheter when the patient (male) was anaesthetized. 
When should the operation be done ? I believe the position held 
by most surgeons in regard to the operation of colotomy, namely, that 
it is only to be thought of as a last means of relief in cases of car- 
cinoma of the rectum and sigmoid flexure, also in strictures of small 
calibre, otherwise incurable, is a too conservative one. We must all 
admit that the chief factor in the rapid growth of carcinoma involving 
the bowel is the irritation to which it is constantly subjected, first, by 
the peristaltic action of the bowel, and, secondly, by the passage of 
fecal matter through the involved portion; therefore, the position I 
maintain is, that the sooner the operation is done, there being, of 
course, no doubt as to the character of the trouble, the better, and for 
the following reasons : First, by the early establishment of an artificial 
anus, the patient is relieved of the severe pain caused by the contrac- 
tion of the enfeebled bowel in attempting to expel its contents; to 
relieve this, it is necessary to administer anodynes which interfere 
wdth digestion and assimilation. Second, the diarrhoea, so frequently 
a common symptom in these cases, does not occur. Third, the danger 
of total obstruction, one of the causes of death in unrelieved cases, is 
prevented. And, lastly, the opportunity afforded of subjecting the 
affected bowel to frequent antiseptic irrigation, by which the progress 
of the disease is very materially stayed. I am convinced that in the 
case of lumbar colotomy I here report, showing a drawing of the 
artificial anus, by frequently washing out the lower bowel with a one- 
half-per-cent. solution of creolin (preventing the collection of the 
excretions of the growth, which cannot be done thoroughly until an 
opening is established with the bowel above the seat of the growth), 
as has been done conscientiously by my resident surgeon, Dr. C. D. 
Hamman, the patient’s comfort has been greatly added to; also, that 
the progress of the growth since the operation has been but little, if 
any. 
Thus far, I have spoken simply of left lumbar and left iliac 
colotomy. Owing to the modern advancement made in intestinal 
surgery, right lumbar and right inguinal colotomy are operations, I 
hope, of the past. I trust, at this time, no surgeon who is abreast 
with the times would think of either of the two last-mentioned 
operative procedures, but would open the abdomen of his patient, 
remove the growth—if possible, by resection—and reestablish the 
continuity of the canal, either by lateral implantation, or, better, 
lateral apposition by perforated decalcified bone plates or rubber 6 
DEAVER, 
rings. Where it is not possible to remove the growth in the cases 
last referred to, sooner than establish an artificial anns, make a lateral 
anastomosis. 
In carcinomatous disease of the upper portion of the rectum, 
colotomy offers the only operative means of relief. In carcinomatous 
disease of the sigmoid flexure, or of the descending colon, too high 
for colotomy, lateral anastomosis by ileo- or colo-rectostomy may be 
feasible, but here I give preference to lumbar colotomy; elsewhere I 
prefer anastomosis. 
James R., hostler, aged thirty-eight years. Admitted to the German 
Hospital July 26,1890. Family history negative. Has had pain on defeca- 
Fig. 1. 
Showing the artificial anus. The two openings drawn apart so as to bring out 
the spur. 
tion, and discharge of blood-stained matter. On examination, an ulcerating 
mass was found high up in the rectum, involving the entire calibre of the 
gut. 
August 16. Left lumbar colorraphy performed. 
11th. Considerable tympanites. LUMBAR VERSUS ILIAC COLOTOMY. 
7 
18th. Gut opened; immediate relief from tympany. Wound was dressed 
twice daily. Primary union. Patient discharged September 6th. 
Fig. 2. 
Pad. 
The patient was able to regulate the movement of the bowels at the end of 
two weeks. He improved markedly in health and strength. 
Fig. 3. 
Showing pad adjusted. 
December 17. Patient has been doing light work as a hostler for six or 
eight weeks. His bowel is washed out twice a week with a one-half-per-cent, 
solution of creolin.