Chapter XLVIII: The Small Intestines (3)

In performing the operation the smallest possible incision should be made through which the appendix may be delivered, its mesenteric artery is tied, and its mesentery stripped down to its origin. At the latter the cecum is fastened to the parietal peritoneum by a suture on either side, avoiding the appendicular artery itself. The balance of the wound is then closed as usual, the appendix being fastened to the lower angle by suture, the protruding part then wrapped with gutta-percha tissue and included in the dressing. At the end of two days the external portion may be divided about 1 to 4 inches from the skin, after which a catheter is passed along its lumen and the stump tied around it. This serves the double purpose of preventing leakage and severing the appendix flush with the skin. The catheter is introduced from 2 to 4 inches, and its external portion left open to allow escape of gas, or doubled and fastened to prevent leakage, as circumstances may require. Irrigation may be begun on the third or fourth day.

When the appendix is used for the purpose of forming an artificial anus it will be probably in instances where there is more of the emergency element present, and it may be sufficient then to simply utilize it for the purpose of anchoring the cecum to the abdominal wall, or with the purpose of dilating it after the expiration of a few hours. In other words, the method may be modified to meet the indication.

It is scarcely necessary to devote space to any other operative procedures upon the small intestine. Consequently it will simply be mentioned here that the upper part of the jejunum can be used for artificial feeding and _jejunostomy_ made to take the place of gastrostomy under those rare circumstances which may demand it.

Upon the large intestine _colopexy_ may be practised, attaching it to the anterior abdominal wall or to the border of the liver or the gastrohepatic omentum. Andrews’ suggestion to attach the colon to the lower border of the liver, after certain operations upon the biliary passages, will be described in connection with the latter. In cases of extreme dilatation, with loss of muscular tone, etc., involving especially the colon, an _enteroplication_ may be practised corresponding to gastroplication, and having the same purpose, with a technique practically identical with the other. Thus when the sigmoid flexure is so dilated as to largely fill the abdominal cavity, with an enormous S-shape, much can be done by thus reducing its dimensions, the only objection being the fear that the causes which produced the condition will conspire to reproduce it even after enteroplication.