A Clinical Lecture ON APPENDICOSTOMY AND ITS POSSIBILITIES
GENTLEMEN,—The patient before us is, as you see, a woman of middle age who is under the care of Dr. W. Ewart. She has been for a long time suffering from symptoms pointing pretty clearly to what is known as ulcerative colitis, by which it is evident she has been reduced to the last degree of emaciation and weakness. The usual remedies having failed to bring about any improvement in her condition I was asked to see the case with a view to affording by surgical means facilities for a thorough
... gation of the whole of the large intestine. The history of the case is set forth in the registrar's notes,l but it is not necessary that it should be given in detail here, as it is sufficient for my purpose to assume that the nature of the case is as I have stated and that irrigation of the large intestine, all other methods having been tried without avail, seemed to be the only feasible plan of treatment. In ordinary circumstances the flushing of the whole of the large intestine is by no means a simple proceeding ; attempts at effecting it by injections from the rectum, however cunningly managed by means of the long tube or otherwise, are necessarily, from the nature of things, often ineffectual, and the only alternatives available until comparatively recently-namely, proximal colotomy or cxcotomyare open to grave objections to which I shall presently refer. I therefore advised that the vermiform appendix should be utilised in this case as a means for introducing the irrigation. Appendicostomy was therefore performed, an operation which has until now been but little used-this is the first time that it has been done in St. George's Hospital-but which has been recently brought into prominent notice by an admirable communication read at the last meeting of the British Medical Association by Mr. C. R. B. Keetley.2 The operation is in ordinary circumstances simplicity itself, as those of you who saw the proceeding in this patient's case can readily understand. An oblique opening into the abdomen in the direction of the fibres of the external oblique at the spot usually selected for the incision for removal of the appendix large enough to admit two fingers is made, the aponeurosis and subjacent muscular tissues being split in the ordinary way. The edges of the divided peritoneum having been held up by pressure forceps one or two fingers are introduced, the appendix is searched for and hooked up, a very simple proceeding if there are no adhesions. In the present case some recent adhesions about the cascum complicated matters a little but caused, as you saw, no real difficulty. The appendix having been thus drawn out through the wound until its base is in contact with the parietal peritoneum is fixed in this position by a fine stitch of catgut or silk passing through the meso-appendix and adjacent edges of the peritoneum, care being taken to see that it is not twisted or kinked in the process. This stitch on being tightened up also serves to diminish the opening in the peritoneum. In order to avoid any possibility of strangulation of the included meso-appendix this suture may be knotted after it has been passed through that structure before its ends are utilised for approximating the edges of the peritoneum. Fixation of the protruding appendix is even more simply effected, when there is no necessity for immediately opening it, by passing a sterilised safety-pin through it on each side between the muscular and mucous coats and closing up the abdominal wound beneath the 1 The details of the case as well as some elementary matters included in the remarks as delivered are omitted in order to economise space.— W. H. B. 2 B r i t . M e d . J o u r . , O c t . 7 t h , 1 9 0 5 . pins (see illustration). On the day following the operation in this case the protruding appendix was divided with sharp scissors a quarter of an inch from the level of the abdominal wall and finally secured in position by two stitches of silk fixing it to the skin These stitches, although probably not absolutely necessary, are desirable in order to avoid any possibility of undue retraction of the stump. No discomfort or other disadvantage has arisen, as you see, from the operation. No reaction of any kind has occurred, and on this the fourth day, so far as the operation is concerned, the patient is unconscious of anything abnormal. A full-size soft rubber catheter passes down the appendix into the cascum without the patient being conscious of its presence ; no regurgitation or moisture comes from the stump. The sphincter at the csecal orifice of the appendix grips the catheter firmly and closes completely after its withdrawal. An ideal state of affairs, in fact, exists for the application of remedies by irrigation, &c., to the whole length of the large intestine by means of an appropriate flexible tube passed into the cascum through the stump of the appendix. A comparison of the condition of affairs existing in this case now with that which would have been present if either of the other alternatives to which I have referredviz., colotomy or csecotomy—had been employed strongly emphasises the disadvantages connected with these, especially the discomfort and at times serious complications which arise from the escape of the contents of the bowel, with the accompanying irritation of the skin about the region of the opening in consequence of the entire absence of spontaneous power of control. Perhaps, however, the most striking superiority of appendicostomy as compared with the other methods mentioned is the ease and certainty with which the adventitious opening can be closed after it has ceased to be of use. All that is necessary in the case of appendicostomy is to cut down and to isolate the stump of the appendix, todeal with it as in a case of removal of the appendix, to drop it back into the peritoneal cavity, and to bring together the abdominal wound in the ordinary way ; the difficulties, on the other hand, sometimes arising in attempts to close the colotomy or caecotomy opening are too well known to require comment. In cases of caecotomy there is the further objection that in consequence sometimes of the free passing away of the contents of the bowel, immediately after they emerge from the small intestine, through the opening in the abdominal wall a condition, in weak subjects, verging upon starvation rapidly supervenes. The occurrence of this case gives me the opportunity for a more general consideration of appendicostomy, an operation, which does not seem to me fully to be appreciated at the present time. The operation, like some other sound surgical methods, was the outcome of pure chance in thecourse of an operation for csecotomy by Dr. R. W. Weir 3 of New York in 1902. Before the cascum had been opened theappendix-with commendable unselfishness on the part of an, organ so much vilified-presented itself in such a suggestive manner that it was at once employed to establish the communication with the casoum. Since that time ni t more than a dozen cases of the operation have been published, two of which are included in Mr. Keetley's paper, to which I have referred. For clinical purposes the possibilities of the operation may be considered under four heads. 1. As a means of affording facilities fur the treatment of certain conditions of the large bowel and possibly of lesions of the small bowel 3 Loc. cit. and New York Medical Record, August 9th, 1902.