Utibilical and Ventral Hernia william H. WATHEN. M.D. BY Professor of Abdominal Surgery and Gy oecology in the Kentucky School of Medicine: Ex-President of the Section on Obstetrics and Gynecology of the American Medical Association: Ex-Pres- ident of the Kentucky State Medical Society: Fellow of the American Gy- necological Society, of the American Association of Obstetricians and Gyne- cologists. and of the Southern Surgical and Gynecological Society: Consulting Gynecologist to the Louisville Ci tv Hos- pital, etc. Louisville. Ky. Ffc;« Tbk Amkhican Jocrxal or Obstctbics XIT11- <_ :«n XKW YOU WILLIAM WOOD A COMPACT. pvbllshus 1W3 UMBILICAL AND VENTRAL HERNIA.1 The importance of studying carefully the best methods of treating hernia is now emphasized because of the increased fre- quency of this disease following laparatomy, and especially be- cause the improved technique in surgery makes the operation far less dangerous than it formerly was. In fact, the operation for radical cure of hernia, which was until recently considered by most of the leading surgeons of this country unjustifiable because of its great mortality and the unsatisfactory results, is now, in the practice of the best surgeons, except in extreme cases, practically devoid of danger, and the patients may be permanently cured. Until we learned the value of surgical cleanliness surgeons were consistent in their refusal to perform this operation, be- cause infective peritonitis was so constantly fatal. Modern an- tiseptic and aseptic precautions have practically excluded this danger, and with its exclusion the patients recover from the operation, and the divided structures unite primarily and bring about a condition that more permanently resists subsequent strains. Hence they not only recover from the operation, but usually have no return of the hernia for many years, if at all. The subject of hernia in its entirety is so vast that it would be useless to attempt, even in the briefest way, to allude to more than one or two varieties in the twenty minutes allowed for reading my paper. I will therefore confine my remarks to the 1 Read before the Southern Surgical and Gynecological Association at Louis- ville, November 16th, 1892. 2 WATHEN : UMBILICAL AND VENTRAL HERNIA. preventive treatment of ventral hernia following laparatomy, and the treatment of umbilical hernia. There are many cases of ventral hernia that could have been prevented had the proper treatment been observed in the clo- sure of the abdominal incision. To prevent hernia following laparatomy it is necessary to get perfect union by adhesion of all the layers of tissue forming the abdominal wall-the peri- toneum, muscles, the deep and superficial fascia, and the skin. But especially must we get union of the layers of fascia, for unless this be done the other layers will gradually separate and hernia will follow. This cannot be done unless we succeed in bringing the cut edges of the fascia in even and perfect apposi- tion long enough for strong union to occur. This is impossible if there is suppuration in the wound, and is generally impossi- ble unless the several layers of tissue be separately united by the buried suture. In operations for large tumors where the abdominal walls are relaxed so that there is no tension upon the wound, all the layers may be evenly and perfectly brought to- gether, and good results may follow, by uniting the incision with interrupted sutures carried through the entire thickness of the abdominal wall. But in four-fifths of the operations that are now done these conditions do not exist, and there is neces- sarily more or less tension immediately upon the sutures. Hence we have no assurance that the several layers are brought into apposition, except it be done by separate union with the buried suture. Some operators claim that they have not had hernia following laparatomies, and that they have sutured the abdomen after any fashion that at the time suggested itself to them ; but if these men will look more carefully into the subsequent his- tory of their cases, they will find that hernia is more frequent than they had supposed. I did not believe, in my earlier lapa- ratomy work, that hernia would follow my operations, and I was bold in asserting that I had no hernia complications; but I now find that I have, and in some of the cases where the immediate conditions were apparently the most favorable and permanent. Of course until recently the buried suture could not be used be- cause of the imperfect knowledge of the best means to protect the wound against infection. This objection having been practi- cally overcome, almost any suture may now be buried in tissues, if properly introduced, and will not cause suppuration. It is necessary to introduce an aseptic suture into aseptic tissue and wathen: umbilical and ventral hernia. 3 exclude it from the atmosphere. There is a precaution, however, in addition to perfect cleanliness, that must always be observed in the use of the buried suture, otherwise we may have suppu- ration. It is next to impossible to do any operation that is ab- solutely aseptic, as there may be a few bacterial spores in the wound or upon the suture; but these are readily taken care of and destroyed by the cellular elements, unless the power of resist- ance is impaired and conditions favorable to their development are furnished. If the sutures are drawn too tightly in all of the layers, or at any point, the normal blood and nerve supply to the part will be interfered with, the resisting powers to bac- terial development weakened, and suppuration may result. In my former operations with the buried suture this difficulty was annoying, but with a broader experience I now have but little trouble in this particular. I have several cases in the Infirmary recovering from laparatomy where the incision was closed with the buried suture; union is perfect, and the tissues about the wound are nearly as soft as the other parts of the abdomen. I prefer the kangaroo tendon, because it is easily made and kept aseptic, and when chromicized holds its integrity long enough to insure perfect union of the surfaces. I do not consider cat- gut so reliable, unless it is prepared by some person practically familiar with the best methods of sterilization, and there is dan- ger of too rapid absorption unless it has been carefully chromi- cized. The entire wound should be closed by the buried tendon. It may be done by the cobbler's stitch, after the fashion of Dr. Henry O. Marcy, or by the continuous and blind stitch, and then hermetically sealed with iodoform-collodion with a few fibres of absorbent cotton spread over the incision. The revolution in the treatment of hernia in the last twenty- five years has been remarkable. Especially is this true in regard to the treatment of umbilical hernia. It appears that the first operation in America during this century, for the radical cure of umbilical hernia, was successfully performed by Dr. Horatio R. Storer, of Boston, in 1866. He was severely criticised by the surgeons of Boston and of this country for attempting such a foolhardy operation. I do not think that any successful surgeon would now decline to operate upon a well-marked umbilical or ventral hernia; and it is the correct thing to operate for radical cure as soon as the hernia is well developed, for the operation is then practically devoid of danger, if properly performed, and 4 WATHEN : UMBILICAL AND VENTRAL HERNIA. the permanent results will be far better than if let alone until the hernia has grown large and complications have arisen that make the operation a difficult one. One of the serious ques- tions formerly considered was the treatment of the sac because of infective peritonitis when it was opened. This danger no longer exists, and in operating for radical cure of a large or old hernia the sac should be sutured at its base and removed. There is no other method of treating the sac that from a surgical stand- point is rational or that brings about a condition approximating the normal condition. These operations, except in cases of strangulation or extensive adhesions, are little more dangerous than an ordinary exploratory laparatomy. But, of course, great care in bringing together the layers of tissue must be observed if we want to prevent a recurrence of the trouble. Fortunately the adhesions are usually omental, which are easily separated and cause no trouble. If there are intestinal adhesions this is a com- plication that must be carefully managed, so as not to impair or destroy the integrity of the bowel. Sometimes in fat persons the sac is tilled with an omentum so large that it cannot be returned unless the ring be widely divided. In these cases, especially if the adhesions are extensive and the omentum somewhat injured in separating them, it should be ligated in sections and removed. This adds very little to the danger of the operation, for large quantities of omentum may be removed with impunity, as I have frequently done. If the contents of the sac, when all the adhe- sions are separated and the recti muscles relaxed, cannot be returned into the abdomen without too much and too long ef- forts, the ring of the hernia should be enlarged; but usually a little nicking at one point of the constriction will be sufficient. When the contents have been returned the thin skin over the hernia should be cut away, and the peritoneum should be re- sected a little beyond the bottom of the ring, so as to better re- freshen the edges above and to be more positive of getting an even, smooth peritoneal surface when it is united. It may occa- sionally be better to resect the ring also. The peritoneum should be closed by a continuous suture instead of ligation in mass. When the sac is removed and the peritoneal edges brought to- gether, the remainder of the operation is extraperitoneal and may be completed without risk of soiling or infecting the abdo- minal cavity. It is necessary to refreshen every part of the sur- faces before we attempt to unite them, and to split the tissues,. WATHEN : UMBILICAL AND VENTRAL HERNIA. 5 and, if possible, expose the fascia so that it also may be united. The number of layers of suture necessary to close the wound will depend upon the thickness of the wall; but two or three layers will be needed in a thin wall, while four or five may be re- quired in a thick wall. If the hernia is small and the parts come easily in apposition, it will not be necessary to use any suture except those that are buried; but in fat people with old and large herniae it may be better to introduce several silk or silver-wire interrupted sutures half an inch from the surface of the incision down nearly to the peritoneum, to act as splints or supports to the buried sutures until firm union has occurred. In such cases, unless the kangaroo tendon or the catgut is large and thoroughly chromicized, it is probably correct to use the silk suture, because it will positively not be absorbed or weakened in its resisting power until union is perfect. If the wound is entirely closed by the buried suture, the best dressing is iodo- form-collodion, as recommended after a laparatomy. These patients should be kept in bed for two weeks after the operation, with a binder tightly fitted around the abdomen ; and when they are permitted to sit up, and for a year afterward, should be re- quired to wear constantly a tight and evenly fitted abdominal support. In conclusion I will report an interesting operation for um- bilical hernia that I recently performed, which was not only immediately successful, but the condition of the united wound indicates that the woman will remain permanently cured. I report this case because it shows a condition as difficult to treat and as dangerous as any we will have to contend with, unless in cases where there is strangulation that has partially or entirely destroyed the vitality of the omentum or the intestine. Mrs. W., Paducah, Ky., set. 53 years, the mother of several children, has had umbilical hernia for about fifteen years ; for several years it has been irreducible, and has increased in size and caused much pain and inconvenience. On September 15th, 1892, she suffered intensely with partial strangulation, which was finally corrected by the persistent but careful manipulation of her physician, Dr. Jewett. He devised and applied a per- fectly fitted abdominal support, and sent the patient to me on September 25th. She weighs two hundred and fifty-one pounds, and the hernia is the size of a man's head and cannot be reduced. On the 27th I performed an operation for radical 6 WATHEN: UMBILICAL AND VENTRAL HERNIA. cure. The sac contained nearly all of the great omentum and the transverse colon. The omentum was firmly adherent; when the adhesions were separated it was torn in many places, and was so large that it was impossible to return it into the abdo- men. It was ligated in sections, and a piece nearly as thick and as wide as a man's hand, and twelve inches long, was removed The ring was so small that it was necessary to slightly nick it before the bowel could be returned. The sac was resected to a little below the bottom of the ring, removed, and closed by a continuous suture. The tissues above were widely split to ex- pose the fascia, and the superfluous skin was cut away. The wound was closed by layers of continuous silk sutures, and several deep silver-wire interrupted sutures were used. She had no untoward symptom, and the structures in the hernial region are so thick and solid that I do not believe there will be a recurrence, though I have advised her to wear a well-fitted abdominal support for a year. Possibly heavy kangaroo tendon or catgut well chromicized would have done as well as silk. No. 628 Fourth avenue. MEDICAL JOURNALS PUBLISHED BY WILLIAM WOOD & COMPANY. MEDICAL RECORD. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. Edited by GEORGE F. SHRADY, A.M., M.D. Price, $5.00 a Year. The Medical Record has for years been the leading organ of the medical profession in America, and has gained a world wide reputation as the recog- nized medium of intercommunication between the profession throughout the world. It is intended to be in every respect a medical newspaper, and contains among its Original Articles many of the most important contributions to medical literature. 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