A New Incision for the Surgery ofthe Bile Tracts.

A. D. BEVAN, M.D.PROFESSOR OP ANATOMY, RUSH MEDICAL COLLEGE; SURGEON TO

PRESBYTERIAN AND ST. LUKE’S HOSPITALS.CHICAGO.

REPRINTED FROM THEJOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.

JUNE 26, 1897.

CHICAGO:American Medical Association Press.

A NEW INCISION FOR THE SURGERY OFTHE BILE TRACTS.

A. D. BEVAN, M.D.

The subject of the surgery of bile tracts is of recentdevelopment. In 1867 Bobbs of Indiana performedoholecystotomy. In 1882 Langenbuch removed thegall bladder, cholecystectomy. In the same year Gas-ton suggested oholeoystenterostomy, which was laterperfected by the introduction of the anastomosis but-ton by Murphy. In 1890 Courvoisier performed andadvocated choledoohotomy, and later the removal ofstones from the cystic duct and hepatic duct werereported.

In the last five years the value and possibilities ofthe surgery of the bile tracts has been so thoroughlydemonstrated, that it is today a recognized field to allmen doing abdominal work.

A few years ago, when I began to do surgical workon the bile tracts, I carefully reviewed the topographicanatomy of this region. I was surprised to find howcompletely the subject had been neglected by bothanatomists and surgeons. And here let me say a wordin behalf of surgical anatomy. It is the boast of somesurgeons of the present brilliant aseptic period thatthey ignore anatomic boundaries and anatomic reason-ing in their operative work. It is so easy to cut andligate and suture deep and superficial structures andobtain primary union, thata careful study of operativeprocedures is regarded often as unnecessary, and is asa rule neglected.

In surgical training, for the time being, anatomy isovershadowed by pathology, and as a result, the sur-geons of today are better pathologists to be sure, butmuch poorer anatomists than the surgeons of the pastgeneration. This is a fault which is often evident

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even in the work of eminent surgeons, and which mustbe corrected. A perfect mastery of the surgical anat-omy is absolutely necessary for the performance ofthe best operative surgery in any field of surgicallabor. This applies with special force to the surgeryof the bile tracts, and yet many operations on thisregion are performed by men who have no clear ideaof the anatomic relations of the parts or of the possi-ble dangers, and who do not see the necessity of pre-paring themselves by cadaver study before undertakingsuch work. Such brilliant work asKocher’s teachingsof making incisions in the lines of normal cleavage,as Bassini’s hernia operation, as Mcßurney’s andMcArthur’s splitting operation for appendicitis, asHartley’s removal of the Gasserian ganglion, as Mc-Ewan’s studies of mastoid disease and brain abscess,as Kraske’s incision for removal of the rectum, are allresults of anatomic studies applied to surgery; theyare what might be called anatomic surgery and theydemonstrate its value.

With the objects of determining the best methodof exposing the bile tracts for exploration and opera-tive procedures, and for determining the position andrelation of the bile tracts to other structures so thatoperations could be conducted with a minimum ofdanger to important structures, I undertook a seriesof twenty dissections. In this brief report I desireto present not the entire results, but one of the resultsof my investigations, namely, the abdominal incisionwhich is best adapted for bile tract surgery.

In my early clinical work I made use of the inci-sions which have heretofore been generally employed.First, the vertical incision along the outer border orthrough the substance of therectus; second, the trans-verse or liver border incision of the Germans; third,the —1 shaped incision made up of an incision alongthe outer border of the rectus and one joining it atright angles; and fourth, the incision in the upperhalf of the linea alba for common duct work.

The objections to these incisions are many. Theycould be summed up in a few words. These incisions

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do not give room for extensive work unless they aremade very long. When they are made very long, theycarry with them the danger of hernia. Every onewho has done much common duct work must realizethe difficulty of obtaining free access to the operativefield through the incisions usually employed, and in

Fig. 1.—Heavy line the primary and light lines the extended portions of incision.

spite of statements to the contrary, hernias afterextensive incisions for bile tract procedures are notuncommon. No surgeon can tell before opening anabdomen for an operation on thebile tracts how exten-sive an operation may be required, and it is therefore

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desirable to adopt an incision which will be suitablefor exploration and simple procedures and which, atthe same time, can be readily extended to meet thedemands of the most extensive operation.

The vertical incision along the outer border of therectus answers very well for cholecystotomy, but doesnot give sufficient room for bile duct work unlessmade very long, and even then the edges of the inci-sion are tense and much traction is required to exposethe field of operation. The result of such extensiveincision is to cut off the nerve supply of the rightrectus muscle and thus weaken the abdominal wall.The H shaped incision can be made extensive enoughto expose the bile ducts freely for operative work, butit is the most objectionable incision that can beemployed. It is difficult to suture properly. It isdifficult to obtain good union at the point where theincisions meet. I have seen necrosis of the sharpcorners of the flaps at this point. It is prone to leavea weakened abdominal wall. In my own limited expe-rience I have had three hernias following this form ofincision; two after nephrectomies and one after ohole-dochotomy.

The transverse or liver border incision is not asobjectionable as the two above mentioned, but it doesnot meet the requirements as completely as the inci-sion which I shall describe. The incision in the upperpart of the linea alba for work on the common duct isobjectionable because it does not give free access to thegall bladder, and in many oases of common duct workthe gall bladder also requires operative treatment.The problem which was before me in my dissectionswas to develop an incision which would answer forexploration and which, in case of need, could beextended sufficiently to obtain free and easy accessfor the performance of any operation required, and atthe same time this incision must impair the integrityof the abdominal wall as little as possible and carrywith it a minimum of danger of subsequent hernia.

The incision which I have developed, I believe,meets these requirements, and as it can now be urged

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both from anatomic grounds and clinical results, I feelwarranted in presenting it to the profession as a smallbut not unimportant contribution to the surgery ofthe bile tracts.

My incision should be divided into a primary portion and the extended parts of the incision. The pri

Fig. 2.—Abdomen opened and anterior layer of lesser omentumremoved. Gall bladder, cystic, hepatic and common duct, portal vein,hepatic artery and branches in view. Arrow in foramen of Winslow.

Mary part, which can be employed for exploration orsimple cholecystotomy, is an italic letter /-shapedincision along or through the outer border of therectus muscle, as shown by. the heavy line in Fig. 1.This may be made from three to four inches in length.The extended parts of the incision are added to this

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when required. These extended portions are seen asthe faint lines in Fig. 1. These extended portionscan be made from an inch to three inches in length asthe thickness of the abdominal wall and the characterof the operation demand. When complete, the inci-sion furnishes much freer access to the gall bladderand bile ducts than can be obtained by any other formof incision. The edges of the incision are readily heldapart without tension, and the-entire bile tract is freelyexposed for examination and operative procedures.

Anatomically the incision injures a minimumamount of the nerve supply of the abdominal wall,because, even though the incision is made of greatlength, the extended parts of the incision run almostparallel with the nerve supply of the abdominal mus-cles. By a division of the rectus in part and of theinternal and external oblique and transversalis mus-cles, the incision can be widely separated withouttension. The fact that the incision is in close contactwith the costal arch makes resulting hernia improb-able, as a cicatrix in the upper part of the abdominalwall does not as readily yield and produce hernia asa cicatrix in the lower portion of the abdominal wall.

The following structures are divided in the incision:Skin, superficial fascia, external oblique muscle andaponeurosis, internal oblique muscle and aponeurosis,transversalis muscle and aponeurosis, rectus muscle,the transveralis fascia, which is here very thin, andthe peritoneum. A few of the terminal branches ofthe intercostal nerves to the rectus are divided, andthe anastomosis between the internal mammary anddeep epigastric arteries in the substance of the rectusis divided and usually needs ligating. The incisionshould not be nearer than three-quarters of an inchto the costal arch.

When the complete incision is made the followingstructures can be seen as represented in Fig. 2: theliver and gall bladder above, the round ligament ofthe liver and the stomach to the left. The duodenum,the transverse colon and great omentum below. Thetransverse colon and omentum should be pushed

Fig.B.—ViewofstructuresseenIn

incisionafter

removalof

anteriorlayerofomentum.

Naturalsize.

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downward, the stomach to the left, and the liver shouldbe held up by the fingers of an assistant. We willthen have exposed to full view the gastro-hepatic orlesser omentum, which contains the following struct-ures between its two layers: the portal vein, thehepatic artery, the common, cystic and hepatic ducts,the gastro-duodenalis artery and sometimes vein, thenerve supply of the liver and the lymphatic vesselsand several lymphatic glands. The foramen of Wins-low is at the right free edge of the lesser omentum.These structures and theirrelations are well seen afterthe anterior layer of the lesser omentum has beenremoved, in Fig. 8. The left index finger can be passedinto the foramen of Winslow and the extra-hepaticducts palpated throughout their extent except the por-tion of the common duct covered by the pancreas.

It must be understood that as a rule in operationson the living siibjeot that the normal conditions arealtered by adhesions and changes in shape and size ofthe gall bladder and bile ducts, but after the separa-tion of the adhesions the relations will be found prac-tically as here represented.

In closing the incision, silkwmrm gut sutures shouldbe passed through the entire wall, the margins of thewound approximated, and then before the silkwormgut sutures are tied, the abdominal muscles and apo-neuroses are sutured accurately with buried catgut.

I believe that the incision which I here present isbased upon good anatomic and surgical grounds andthat its adoption will be a step in advance in the sur-gery of the bile tracts. It makes better work possibleby giving freer access to the field of operation; it willenable the surgeon to work more rapidly and in someof the prolonged operations on the bile ducts this is avitalpoint. It will reduce to a minimum the dangersof hernia after these operations. It can be employed inall cases, in exploration, limited or extensive oper-ations.

The accompanying plates were drawn from my dis-sections by Dr. J. D. Freeman of the house staff ofthe Presbyterian Hospital.