VENTRAL HERNIA RESULTING AFTER ABDOMINAL SECTION AND ITS TREATMENT. BY ANDREW F. CURRIER. M.D. NEW YORK. Reprint from July number. Vol. X, Annals of Gynecology and Pediatry Boston. 1897. VENTRAL HERNIA RESULTING AFTER ABDOMINAL SECTION, AND ITS TREATMENT.* ANDREW F. CURRIER, M.D. The great number of cases of ven- tral hernia which were observed a few years ago as the sequel of abdom- inal section, happily led to a careful revision of the technique of closure of the abdominal incision and to various modifications of the same. The substitution of the vaginal for the ventral avenue of approach in the surgery of the abdomen and pelvis, on the part of many surgeons, has still further tended to limit the num- ber of accidents of a hernial charac- ter. There are still many surgeons, with more or less experience in the vaginal method of operating, who are unwilling to abandon the tried and satisfactory incision through the ab- dominal parietes. Into the merits of this controversy, however, I do not propose to enter at this time. There will probably remain a larsre number of cases, in any event, in which it will always be deemed preferable to use the abdominal incision, either central or lateral, no matter what our prejudices or preference may be, and hence the possibility of future her- nias. Especially will those cases be exposed to this risk in which an incis- ion in the loin is requisite, the mus- cle and fascia often affording less pro- tection in this locality than in the central portion of the abdomen. This subject, therefore, cannot be dis- missed as one which is deficient in practical utility. The cause of ventral hernia is by no means identical in all cases. It may be due to imperfect apposition of homologous structures, to an insuf- ficient number of supporting sutures, or to too large a number, to prema< ture removal of the sutures, to insuf- ficient protection of the abdominal wall after the patient has left her bed, to undue strain and tension upon the tissues involved in the wound, or to defective vitality in these tissues. It does not follow that hernia implies imperfect technique on the part of the surgeon, for it may occur when no flaw of such a character is demon- strable. It is well to recall, in this * Read l>efore the American Gynecological Society at its meeting in Washington. D. C., May 5. 1897. ANDREW F. CURRIER 2 connection also, that with the occur- rence of the menopause which fol- lows many of the operations in which the abdominal parietes are divided, there is a tendency to unusual devel- opment of adipose tissue in that por- temperature, and are addicted to the excessive use of alcohol, hernia may be expected to result in no small per- centage of cases. Such hernias are not directly attributable to faulty op- erations, and cooks, laundresses, and scrub-women have occupations which render them very susceptible to the accident. A tendency to hernia is present in the tuberculous, the syphilitic, and all others whose tissues are essential- ly depraved and deficient in resisting power, and the same is true of those with whom the line* of union has been weakened by the use of the drainage tube, or the* gauze packing, or with whom the union has been by granulation after more or less exten- sive suppuration. There are three varieties of hernia which I have observed as the sequel of abdominal operations which may be denominated (1) the simple, Fig. 1; (2), the multiple, Fig. 2, and (3), the massive, Fig. 3. This distinction becomes necessary for the treatment, at least in my experience, differs for each. The order in which the tis- sues separate in the development of hernia is immaterial, indeed I do not know that any observations upon this point have been recorded. What has been observed is that the muscles and the firm sheath of fascia split apart when the vis a ter go becomes sufficient, and the peritoneum, usually, but not always intact, with the abdominal contents which are be-* hind it, are projected forward into the opening. The peritoneum, if un- Fig. 1. (Profile.) Variety 1, simple. tion of the body, and sometimes to fatty degeneration of structure as well. When such a condition occurs in women who are obliged to work hard and continuously to earn their living, especially if they work in an elevated VENTRAL HERNIA. 3 ruptured, soon becomes adherent to the skin, while the omentum and in- testines may or may not adhere to the peritoneum. The danger of stran- gulation with this form of hernia is not great, the danger is rather that the rent in the abdominal wall will increase in length and the volume of the hernial sac increase proportion- ately. In the simple variety of ven- tral- hernia (Fig. 1), the lateral re- traction and stretching of the mus- cles and fascia progress, there is a de- cided development of connective tis- sue binding the structures firmly to* gether, and very often the formation upon the abdominal wall of a thick overlying mass of fat, so that the muscles are entirely buried from sight until the fat is dissected away. The muscles, as a rule, do not lose their function, and except for the weakening of the abdominal wall and the sense of insufficient sunnort at the seat of the hernia, the patients may not be conscious of any great incon- venience or pain. Indeed, the dis- comfort is sometimes so inconsider- able that it is frequently difficult to persuade them to submit to an opera- tion to restore the structures to their normal anatomical relations. In the second variety of ventral hernia (Figs. 2 and 4), the condi- tions are more complicated. It oc- curs in women with weak and flabby tissues, and with general tendency to the development of adipose. There is great retraction of the muscles and fascia, with fatty degeneration, the muscles being pale and poorly nour- ished and the fascia thin and yield- ing. The hernia is not only in the central line, but in more or fewer lo- cations in other portions of the ab- dominal wall. The reduction of these various herniae and the dissection and FlG. 2. (Profile.) Variety 2, multiple. resection of the redundant and un- necessary tissues is a task which con- sumes much time and patience. For- tunately, this variety is the least fre- quent of the three. It gives rise to a very decided sense of weakness and insufficiency in the abdominal wall, 4 ANDREW F. CURRIER. Fig. 3. (Protile.) Variety 3, massive. and may entirely incapacitate a wo- man from earning her living. It is al- so not devoid of danger, for strangu- lation in the accessory pouches is an ever present possibility. (See Figs. 2 and 4.) The massive variety of ventral hernia (Fig. 3) is sufficient- ly indicated by the name. It in- cludes all cases in which the hernial pouch is of the size of a child's head or larger. It may occur from the sudden rending of the entire scar which results from the abdominal wound, or by gradual development from the simple variety. When the process is gradual and the perito- neum has ruptured, a well-marked ring of fibrous tissue may be devel- oped at the peritoneal border (Fig. 5). The contagious peritoneum may also undergo great thickening, and folds and pouches innumerable may make the situation a complicated and perplexing one. The intestinal mass may be reducible or irreducible; in the latter case the contour of the entire abdominal cavity undergoes change, and it is possible that the VENTRAL HERNIA 5 Fig. 4. (En Face.) Variety 2. multiple. function of the intestines may suffer modification. The development of a great mass of fat adds to the diffi- culty, and presents a very knotty problem for solution. The question naturally arises whether it is proper in all cases of ventral hernia to advise the patient to submit to an operation for its re- lief. In my opinion this question should always be answered affirma- tively. The discomfort from the hernia may be slight and the danger of strangulation small, but it is al- most certain that the same or a sim- ilar force which produced the orig- inal rupture will enlarge and ex- tend it. Such a process may be gradual, but it is difficult to understand hov; it could fail to take place if the pa-« tient occupied herself with the ordi- nary avocations of life. With hard- working women, the volume of the hernia usually increases rapidly, es- pecially if they are careless as to the protection of the abdomen by a suit- able bandage. The symptoms of ventral hernia are so similar to the well-known symptoms of intestinal hernia in other locations, that it would be su- perfluous to say more than that they vary from absolutely no discomfort- in the simplest cases, to complete in- capacity for ordinary muscular toil in the most severe. The occurrence of this accident naturally excites the attention of the patient from its very conspicuous- 6 ANDREW F. CURRIER. Fig. 5. ness. Should she then consult a phy- sician who is without surgical ten dency or experience, he would prob- ably recommend the use of a band- age or truss. Such advice, which might be entirely suitable for an or- dinary inguinal or femoral hernia, would not be appropriate for the vari- ety which is now under discussion. In the former case, the intestine has escaped through a natural passage, in the latter, through one which is artificial, and the line of rupture is prone to extend until the original wound is reopened, or a fissure of even greater extent produced. Hence prudence and common sense dictate the radical surgical treatment of the injury at the earliest practicable mo- ment. The surgical treatment of ventral hernia in its earliest stage is simple enough; the old wound should be re- freshed throughout its entire extent unless it is quite evident that the tis- sues are perfectly strong and secure -above and below the hernial open- ing. The retraction of muscles and fascia is then onlv moderate, and it is an easy matter to bring homologous tissues into apposition. It is quite possible to pass the ligatures through all the tissues, including the peri- toneum, without opening the peri- toneal cavity, until they have been passed. This implies, of course, the 7 VENTRAL HERNIA. Fig. 6. certain knowledge that none of the abdominal viscera are in imme- diate contact with the perito- neum and the peritoneal sac must be cut off before the ligatures are tied. In the more voluminous hernias which have been developing during months and vears, and in which the retraction of muscle and fascia has been considerable, the task is more difficult. In these cases it is well to open the perieoneal cavity at once. It may not be possible to locate the retracted tissues by palpa- tion from without, but they can be readily found by palpation from with- in. Once found, they must be dis- sected out, superfluous peritoneum, fat, and connective tissue removed and homologous structures approx- imated. If after free dissection the tension upon the approximated tis- sues should be great, this tension must be relieved by appropriate lon- gitudinal parallel incisions in the contiguous tissues (Fig. 6). In the massive variety of hernia, the libera- tion of the muscle and fascia with its attendant extensive dissection by no means completes the preparation of the tissues for reunion. The hyper- trophy and redundancy of the peri- toneum in such cases may be enor- mous. As was observed in a previous por- tion of this paper, this variety fur- nishes us with a well-marked fibrous ring (Fig. 5), if the original rupture 8 ANDREW F. CURRIER. Fig. 7. involved the peritoneum. The strength of this ring may be great and beautifully illustrates nature's conservative efforts to replace the normal protection to the abdominal viscera. This ring must be entirely removed, the folds and reduplications must be smoothed out and drawn to- wards the abdominal opening as a centre, and all excess must then be trimmed away in order to restore the norma] anatomical relations. The peritoneal hypertrophy may be at- tended with the development of very large veins which should be ligated before the tissue is exsected (Fig. 5). By no means the simplest part of the operation consists in the removal of the excessive accumulation of fat which is present in many cases. Fail- ure to exsect it sufficiently in all di- rections from the wound will, by ex- erting too much tension or pressure upon the wound, endanger its per- manent integrity. A great fold of fat constantly protruding is very un- sightly and must also be a source of more or less discomfort (Fig. 7). VENTRAL HERNIA 9 In the multiple variety of hernia the opportunity for effective work upon the weakened and degenerated tissues seldom exists. The tissues are all in a bad state of nutrition, the recti muscles mav have disappeared to so great an extent that it would be well nigh impossible to bring them into apposition, and the fascia is so friable, that it is best to interfere very little with it. I have content- ed myself in such cases with laying bare the central hernial sac, remov- ing it and the pouches which are con- tiguous to it, and then closing the wound, uniting such tissues as could be brought into apposition without great tension. Other hernial pro- trusions are then treated in a similar manner, the incisions being in lines parallel to the central incision. One of the most important feat- ures in connection with this operation has to do with the suturing of the wound. The object in view is to bring the freshened tissues into con- tact so accurately and keep them in contact so long that when the sup- porting sutures are removed the un- ion will be as firm as could ever be expected with the conditions which are inseparable from the individual. Experimentation with the various substances which have been em- ployed for suture material, has satis- fied me that worm-gut in the greater number of cases, fills the require- ments more completely than any other. Numberless cases of infection with catgut, however prepared, render it at least of doubtful safety for long sojourn in the tissues. Metallic su- tures have the very desirable prop- erty which resides in a permanently aseptic material, but they are not suf- ficiently pliable for manipulation as other suture material may be manip ulated. Silk may become infected within the tissues though it may have been sterile when introduced. Worm-gut may also become infected and irritat- ing, but this occurs less readily than with other sutures of animal material, and in my experience the number of cases has been very small. This has led me to repose greater confidence in its innocuousness than in any other animal suture. If too much of it is used in a given wound the nutrition of the tissues will be impaired, and I have seen troublesome dermatitis without suppuration, caused by four tiers of such sutures in a thin abdomi- nal wall. The extreme limit of toler- ance of this material by the tissues, in my experience has been three to four weeks. When retained for a longer period it becomes hard and irritating, and suppuration may ensue. Experi- ence which demonstrated this fact long since convinced me that it was not adapted for permanent use as a buried suture. Soft tissues like the fat, the muscle and fascia which have undergone fatty degeneration, and the skin in alcoholics and others with whom the general physical condition is depraved do not sustain favorably the tension of tightly drawn sutures. For such cases the metallic sutures, 10 ANDREW F. CURRIER especially silver wire of rather coarse drawing, furnish a bet- ter and more enduring sup- port than even the worm-gut. Nec- essarily they must be interrupted, rather than continuous, and if they can be retained two weeks or longer without cutting the tissues, the result will usually be favorable. Such su- has given satisfactory results in a number of cases. It is a continuous suture, a modification of the buried suture, and suggested itself in view of the advantages to be derived from prolonged support of the tissues and the disadvantages of the permanently buried suture. I have used it as a tier suture, that is with separate in- clusion of the peritoneum, another separate inclusion of the skin and subcutaneous structures, endermical, and a third tier including the mus- cles and fascia. The peritoneal su- ture has been discarded as unneces- sary and superfluous, and instead of the endermic suture, a continuous cutaneous one may be used if it is preferred except in cases in which the tissues to be united are very voluminous, when it will be bet- ter to use an interrupted one in- cluding the skin, muscle and fascia. The essential suture is therefore the one which enters the abdominal pa- rietes just beyond the upper angle of the wound, traverses the tissues be- low the skin and subcutaneous fat from end to end of the wound, and emerges just below the lower angle. If the wound is not more than three inches long, only one suture, of this character, will be required (Fig. 8). If it is longer than three inches two sutures are preferable, one of them beginning beyond either angle, and both terminating near the center (Fig. 9). It is obvious that the long- er the sutures the more difficult will it be to pull it out through the vari- ous tissues which it has engaged. tures should include all the tissues in the abdominal parietes, should be passed at intervals of a third of an inch, and additional sutures between them should include the skin, subcu- taneous fat and the sheath of the rec- ti muscles if the latter can be liber- ated and brought to the central line. For hernias in which the wound is not more than four inches long, I have adopted a method of suturing which Fig. 8. VENTRAL HERNIA. 11 I first began to use this form of su- ture about a year and a half ago, and the method of introducing it is as fol- lows: A strand of coarse worm-gut twelve inches or more in length is in- serted at its ends into two strong, curved needles sufficiently long to penetrate all the tissues of the abdo- men. Both needles are introduced into the abdomen just beyond the up- per angle of the wound about half an inch apart, from without inward. The sides of the wound are then brought into apposition by successive stitches of continuous suture, includ- ing peritoneum, fascia and muscle, from below upward, and then from above downward, changing tho needle to the opposite side with each successive stitch, precisely as one would lace a shoe. The suture must not be drawn too tightly, for that would pucker the tissues. If two su- tures are to be used, i. e., one for each half of the -wound, the ends of each must penetrate all the tissues, includ- ing the skin, and emerge near the middle point of the wound. After these ends have been tied, each to its appropriate fellow, the gaping skin is to be closed by continuous or inter- rupted suture whichever seems the more suitable, as has already been re- marked. A minor point which is not without practical importance consists in protecting the skin at the begin- ning and end of each suture by a thin strip of gauze which is passed under each loop. The wound may be sealed with iodoform collodion, or not, as preference may dictate; I have found it useful. The dressings which cover the wound may remain unchanged, if the case proceeds normally, for two weeks. They are then removed and with them the superficial sutures. If the deep sutures are causing no trouble they may remain two weeks longer. By this time the tissues will Fig. 9. be as firmly united as they will ever be, and the sutures are not only no longer useful but act as foreign bod- ies which may cause trouble at any moment. To remove them the ends which were tied are cut, the loop at the initial points is gently pulled and with moderate traction each suture is removed. If the tissues offer great resistance to their removal, cutting 12 F. S. CLARK. the loop and drawing on each end separately will facilitate the opera- tion. An anaesthetic should be'given if severe traction becomes necessary, but such an emergency is infrequent. I have usually removed them with very little trouble and without the in- fliction of severe pain. The patient is kept in bed while the sutures are in situ and for a few days after their removal. As an additional safeguard I prescribe the wearing of a suitable number of straps of rubber plaster over the abdomen until the function of the tissues in their renewed condi- tions is fully established. 120 E. 34th St., New York City. Annals of GYNECOLOGY AND PEDIATRY. xl monthly journal of Gynecology, Obstet- rics, Abdominal Surgery and the Diseases of Children; devoted to reliable pathology, clean surgery, accurate diagnosis, and sensible therapeutics. Subscription Price - $3.00 per year, 16S NEWBURY ST., BOSTON, MASS.