THE EXPLORATION OF THE ABDOMENAS AN ADJUNCT TO EVERY

CELIOTOMY.

BY

HOWARD A. KELLY, M.D.,OF BALTIMORE.

1 RUM..

THE MEDICAL NEW#,December 16, 1899.

[Reprinted from The Medical News, Dec. 16, 1899.]

THE EXPLOR AT / ON OF THE ABDOMEN AS ANADJUNCT TO EVERY CELIOTOMY.

HOWARD A. KELLY, M.D.,OF BALTIMORE.

I had occasion in several instances some sixteenyears ago, to make post-morten examinations and toremove through an opening in the vaginal vaultin women, and through the perineum andthrough the rectum in men various viscera whichI was desirous of inspecting. 1 I was enabled in thisway to secure specimens not only from any part ofthe abdominal cavity, but by perforating the dia-phragm, from the thorax as well, removing in oneinstance both heart and lungs. I recall with partic-ular distinctness my first case, a woman with largewhite kidneys whose history I had followed with un-usual interest, and where I had reason to feel as-sured I would be refused the privilege of an autopsyby the unintelligent relatives, abetted by the under-taker. I was in this instance able to remove bothkidneys through the vault of the vagina withoutleaving any external evidence whateverof the depre-dation committed.

I cite these cases, not without considerable mis-givings as to the propriety of my conduct in thusstealing an autopsy, in order to show how easy it isto reach all the various viscera through an incision

1 A method of post-mortem examination of the thoracic andabdominal viscera through vagina, perineum and rectum, withoutincision of the abdominal parietes.—Medical News, June 30,1883. - 7 “—

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as far as possible from the center of the abdomen,large enough to admit the forearm, as well as to urgethe propriety, or rather the necessity of making asomewhat analogous investigation of all the abdom-inal viscera every time the abdomen is opened in theliving subject.

Although I had not infrequently made such exam-inations from the earliest years of my work,in com-mon I suppose with other I was led toadopt the investigation of the abdominal and pelvicorgans as a routine plan to be followed in allceliotomies by the following circumstance whichcaused me no little chagrin. I was treating awoman for pelvic peritonitis with adhesions bindingdown both tubes and ovaries; I first broke up theadhesions under anesthesia, and then, finding thatshe continued unrelieved, in December, 1894, Iopened the abdomen, brought the adherent tubesand ovaries up out of the incision, carefully freedall adhesions and returned the now fairly normal or-gans, and finished by suspending the retroflexeduterus.

She passed entirely out of my hands and I did nothear from her again further than to realize that thesuccess of my work was but a qualified one, until anumber of months had elapsed, when she wrotefrom a distant point saying that she had undergonean operation for chronic appendicitis by which shehad been entirely relieved, and that she was con-vinced that this had been the real cause of all herdiscomforts as well as of the pelvic inflammationwhich I had been treating.

Whether the reproach was deserved in this case I

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have had no means since then of deciding, but Iacted upon the assumption that I was blamable for

Method of exploring; the abdominal viscera.

neglect and took the lesson to heart, and have eversince that date inspected the vermiform appendix inevery instance in which I have made an abdominal

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incision large enough to permit such an examina-tion, and have recorded its condition in writing ona slip kept by the anesthetizer during the operation;furthermore, realizing that not only the appendixmight be at fault but some other abdominal viscusas well, I have made a systematic examination ofthe entire peritoneal cavity in every instance inwhich the conditionof the patient did not forbid it.

It will, I am sure, be easy for any surgeon towhom this proposition is presented for the first time,upon pausing to consider the matter to adduceshortly a number of excellent reasons why such apractice should sometimes prove serviceable; let us

consider some of them.In the first place, abdominal diseases of all kinds

are commonest in middle life, the period when mostof our celiotomies are performed and it becomespractically certain, reasoning simply from the lawof chances, that a coincidence of two or more en-tirely independent diseases is sure by means of thisexamination to be discovered occasionally.

In the second place, there is a constant associa-tion between certain abdominal surgical affectionsand affections elsewhere in the form of a mutual in-terdependence, whether from the propagation of a

disease from a central point, as in the case of can-cer, sarcoma and tuberculosis, or from a mechanicalaction, where the effects of pressure are manifestednear to or at a distance from the seat of the disease,as in the case of pelvic tumors or inflammation ob-structing the vascular, the urinary or the alimentarychannels.

In the third place, such an examination if nega-

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ative gives both operator and patient a comfortableassurance that the convalescence will progress with-out interruption, as well as the satisfaction of realiz-ing that there is no visceral affection in progresswhich is liable in the near future to shorten life orto impair health.

The following diseases are most likely to be foundin such a routine examination: appendicitis, hernia,either inguinal, femoral, or umbilical, hydro-ureter,disease of the omentum, pyloric cancer, movablekidney, enteroptosis, cancer of the liver, perihepati-tis, gall-stones.

In making an investigation,or rather in taking aninventory of the abdominal cavity in this way, cer-tain of the organs can be inspected as well ashandled, while others can only be felt. The rangeof vision is limited to the area adjacent to the in-cision and those structures which can be drawn overinto the neighborhood of the incision; the field isof course extended by enlarging the incision. In alax or scaphoid abdomen where the reserve spaceis large, the abdominal walls may sometimes behooked up well away from the viscera, which can beseen by stooping down and looking in or by insert-ing one of my largest calibre rectal specula andusing a headlight. This extension of the field of in-spection is also often feasible after removing a largeovarian or a large fibroid tumor.

There are four steps in the exploration of the ab-domen:

First, the simple inspection of such structures as

can be seen in the neighborhood of the incision bydrawing the lips gf the incision widely apart,

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Second, the examination of those structures whichcan be brought into view by inserting two fingersthrough a small incision and catching structures nearby, such as ovaries, tubes, cecum and appendix, as

well as uterus.Third, by the insertion of the hand as far as the

wrist, by which the colon and the stomach and thepylorus can be grasped and palpated or pulleddown, and

Fourth, by the insertion of the forearm in orderto reach the liver, the gall-bladder, the kidneys andthe spleen.

The technique of such an exploration is this: ex-treme care must be taken to maintain asepsis bythoroughly sterilizing the arm or by wearing a rub-ber glove with a long sleeve reaching as far as theelbow, which I have had made for this particularpurpose. (See fig. 2.) If the field of the opera-tion, that is to say the area in the immediate neigh-borhood of the incision, is so septic as to demandthe use of drainage, then the operator would bestforego the advantage of the more extended examina-tion on account of the risk of distributing the sep-tic material.

The length of incision necessary for a completeexploration of the abdomen must vary from ten ortwelve centimeters up to fifteen (6 to 9 inches)accord-ing to the size of the operator’s forearm; it must beso large that he runs no risk of bruising the tissuesby forcing in the arm through a tight opening.

The best posture in which to examine the patientis either lying flat on the table, or with the pelvisslightly elevated; a decided elevation often causes

7the appendix to gravitate up out of reach for in-spection unless one uses dangerous traction onthe cecum to bring it down.

The various structures are examined in an orderwhich must vary with the location of the incision;when the abdominal opening is made low down overthe middle of the pelvis, I commonly follow somesuch routine as this; after carefully noting theconditionof each pelvic viscus, uterus, tubes, ovaries,bladderand rectum, I then look at the internal inguinal

Fig. 2.

Rubber gauntlet.

rings, locating them if necessary by the round liga-ments, and test them with the index finger to see ifthere exists a hernia, and if sol proceed to sew it upat once from the inside of the abdomen, first passingthe needle through the outer pillar of the ring andthen through the inner, using one or two mattresssutures of silk; another row of sutures draws the peri-toneum over the first line so as to bury them; inthis way the hernia is closed from the inside, theside on which the pressure falls first and, therefore

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in the position of the greatest mechanical advantage.The umbilical ring is next examined, and if there

is an opening it must be closed in like manner fromthe inside with one or two mattress sutures. Thebladder is then examined for adhesions, which areoften found on its peritoneal surface. The rectumalso will often be found involved in a pelvic perito-nitis, especially near the pelvic floor.

The next point of importance is the vermiformappendix, for which the pelvis ought not be elevatedat all. Unless the abdominal walls are thin, the in-cision must be larger than that used for suspensionof the uterus by my method, that is to say over 4 or5 cm. in length. The cecum can be best caughtand drawn into a small incision by grasping thebowel in the right iliac fossa by the last phalanges ofthe index and middle fingers, between the dorsalsurface of the index and the palmar surface of themiddle; in this way the appendix can be broughtinto view when the incision is only large enough toadmit two fingers.

The cecum secured and brought out, the appendixis traced by following the anterior band of longitud-inal muscular fibers, and when found it should beremoved if it shows any traces of previous inflamma-tion. In a series of 115 cases in which the condi-tion of the appendix was noted at the operation, itwas found adhering to the right tube or ovary in 1 ocases, in 37 cases it was involved in adhesions, itwas congested in 3 cases, and obliterated at the cecalend in 1 case. Only 64 appendices were perfectlynormal.

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In a series of 200 abdominal sections I have hadoccasion to remove the appendix 25 times.

The routine inspection of the ureters in gynecolog-ical operations is perhaps as important as that ofany other abdominal organ after the appendix, andfor this reason every surgeon should be thoroughlyfamiliar with the ureteral landmarks. The best placeto find the ureters is where they lie upon the commoniliac arteries at the pelvic brim; on the right sidethe ureter may be seen, upon lifting up the innerborder of the cecum, crossing the brim with theovarian vessels. If watched for a little while a peri-staltic wavelet, at once establishing its identity be-yond a doubt, will be seen traveling down towardthe bladder. On the left side it is necessary todraw the sigmoid flexure in the same direction, thatis to say, toward the median line, in order to affect asimilar exposure. In cases of carcinoma and myomauteri and ovarian cysts such an examination willoften reveal the presence of a hydro-ureter, in sup-purative pelvic affections apyo-ureter may be found.

A case which I operated on in Paterson, New Jer-sey, at the request of Dr. J. C. McCoy, servesbeautifully to illustrate the point I wish to makehere. The patient had a fibroid uterus reaching ashigh as the umbilicus, and altogether about as largeas a six-months’ pregnancy. I removed it by mymethod of supravaginal amputation, cutting fromleft to right. I then examined the adjacent struc-tures and found the appendix bound down by adhe-sions in the pelvis and removed it. Then afterstating to a number of gentlemen who were presentthe importance of examining the ureters also in such

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cases, I proceeded to investigate carefully and foundon the right side an extensive pyo-ureter leading upto a pyonephrosis, whose presence there had been noclinical reason whatever to suspect.

I accounted for the pyonephrosis in the followingmanner: the myomatous uterus which filled the pel-vis had backed up the urine by pressure at the brimcausing a hydro-ureter and a hydronephrosis, thencame the appendicitis adding the element of infec-tion conveyed through the tip of the appendix whichI found firmly soldered down in the pelvis upon theureter about 4 cm. below the brim of the pelvis.

Dr. McCoy at a later date removed the right kid-ney, completely curing the patient. By making a

routine examination of and discovering the com-plication at the first operation, I saved myself thepossible, and I think proper, imputation of havingligated the ureter, and so of having caused thepyelonephrosis, I furthermore made an accuratediagnosis as to the presence and location of thecomplication and determined that the opposite sidewas unaffected, so making the subsequent operationa safe instead of a hazardous undertaking.

The position of the transverse colon and thestomach are to be noted on account of the frequencyof enteroptosis.

Up to this point it has only been necessary to in-troduce the hand as far as the wrist, it now becomesnecessary to introduce the forearm, and for this pur-pose the edges of the incision are protected withgauze, and the omentum held down while the handis pushed in, in front of it, with fingers extendedand thumb pressed into the palm so as to take up

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less space. Whichever hand the operator uses heshould stand on the corresponding side of the patientand push the hand first back into one flank and theninto the other and thus palpate both the kidneys,noting their presence, size, form, and mobility bysliding them up and down. The renal pelvis maybe felt and inverted towards the calices to detecta stone. After the kidneys, the liver is felt, its ap-parent size, the regularity of its surface, its margin,any adhesions which when present indicate perihep-atitis. Most of all, the superior viscera the gall-bladder is next located by feeling the fissure betweenthe right and left lobes of the liver and then pal-pating across the lobus quadratus to the depressionon its right side where the gall-bladder is found, asa rule, well distended.

By taking it between the thumb and two fingersand squeezing it with moderate force, a healthy gall-bladder collapses slowly as the bile is forced out intothe hepatic and common ducts. Not infrequentlyon recovering from the anesthetic such a patientvomits at once a quantity of golden-yellow bile.When the gall-bladder is collapsed one can thenreadily feel a stone if it be present, by pressing itswalls together.

I next put my index-finger in the foramen ofWinslow, easily found below the gall bladder, andpalpate the hepaticoduodenal ligament and tracethe common duct down for several centimeters,feeling for a stone there. The spleen may then befelt, taking the stomach as a guide.

Finally the pancreas is found by carrying the

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hand in under the omentum and palpating throughthe transverse mesocolon.

The aorta may be palpated thoughout the entirelength of its abdominal portion by pressing the fin-gers back against the vertebral column as the handis withdrawn.

In a case of Dr. G. P. Yost’s, in which a patientconvalescent from typhoid fever was suddenlyseized with severe pains, marked elevation of tem-perature, and had a decided distention of theabdomen, there was reason to suspect an attack ofacute appendicitis or perforation of the intestine.In this instance I made an incision just inside theanterior superior spine of the ilium, and finding thebowel and appendix normal but the peritoneumeverywhere in a state of subacute inflammation, andthe abdominal cavity full of a dark thickish fluid, Iexplored the rest of the abdomen through the incis-ion and was rewarded by finding a gall-stone in thebladder. A close examination of the fluid showedthat it was probably bile, and the diagnosis of rup-tured gall-bladder following typhoid fever was there-fore made and the abdomen opened above, thestone removed and the gall-bladder drained and thepatient recovered.

In another instance in which the patient locatedher pains under the liver and there was every rea-son to suspect the presence of gall-stones, uponfinding none I palpated all of the abdominal viscerathrough the incision made in the linea semilunarisjust below the ribs and found far down on the pelvicfloor a large hematoma of the left ovary which wasat once removed by a suprapubic incision.

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I shall not pause to cite cases in which isolatedcarcinomatous nodules have been found uponcarefully searching through the omentum, or en-larged mesenteric glands in peritoneal tuberculosis;or in other cases in which a carcinomatous infil-tration has been discovered in the pylorus ornodules in the liver, in each instance materiallyaffecting the prognosis as to complete recovery.

In cases liable to metastasis, such as those justcited, it is my practice to reverse the order of theinvestigation wherever possible, making the explor-ation of the abdominal viscera first and then doingthe operation. If I find a metastasis which is outof the reach of surgery, I would not then feel justi-fied in taking the same risks in removing say an ad-vanced carcinoma in the pelvis.

In conclusion let me recapitulate and restate thepoints I desire to emphasize presenting them from aslightly different standpoint.

The important lesson I wish to inculcate is that,provided an incision has been made in theabdominal parieties large enough to admit theentire hand and therefore the forearm, it is alwaysan advantage to the patient to be able to assure himthat as far as touch could ascertain there is no dis-ease of any other abdominal organ.

Under some circumstances where there is reasonto suspect disease of one of the other viscera not inthe proximity of the field of operation,! would makea larger incision than necessary for the performanceof the operation for the very purpose of making suchan exploration.

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There are in general three classes of cases towhich this extended examination may be applied:

Firstly, those in which there has been no reason

to anticipate any disease of any other organ and theexamination is made simply as a routine procedure,whenever it adds nothing to the gravity of the situ-ation. In such cases we are most liable to find un-suspected hydro-ureter, appendicitis, movable kid-ney, gall-stones, and occasionally pyloric tumor.

Secondly, those cases in which on opening theabdomen, contrary to expectation no disease is foundnear at hand. The operator may then find it ofgreat advantage to enlarge the incision, introducethe hand and the forearm and explore the entireabdomen. I have cited a case of this sort in whichI made an incision over the appendix and finding noappendicitis, enlarged the opening and found a gall-stone within a ruptured gall-bladder; also, anothercase in which gall-stones were believed to be present,but in finding the diagnosis at fault I introducedmy arm through the enlarged incision and found alarge hematoma of the ovary.

Thirdly, the group of cases in which there is adefinite percentage of chances that the disease dis-covered at the time of operation is complicated bythe affection of some other organ neighboring orremote. In cancer of the ovary I examine all theorgans and in no small percentage of cases have thedisappointment offinding metastases in the omentumpylorus, or liver. In pelvic inflammatory diseasethe appendix will be frequently found involved, andin the case of pelvic tumors as well as inflammationthe ureters are prone to suffer from compression.

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