Entero-Plastic Operation to Overcome or 
Prevent Stenosis, 
With Especial Reference to the Spur in 
Preternatural Amis. 
BY 
CHRISTIAN FENCER, M.D., 
PROFESSOR OF SURGERY AND CLINICAL SURGERY, NORTHWESTERN 
CHICAGO, ILL.; 
UNIVERSITY MEDICAL SCHOOL. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
April, 1899. Extracted from The American Journal of the Medical Sciences, April, 1899. 
ENTERO-PLASTIC OPERATION TO OVERCOME OR PREVENT 
STENOSIS, WITH ESPECIAL REFERENCE TO THE 
SPUR IN PRETERNATURAL ANUS. 
Christian Fenqer, M.D., 
CHICAGO, ILL., 
PROFESSOR OF SURGERY AND CLINICAL SURGERY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL. 
The principle of overcoming a stenosis of a canal by transverse union 
of a longitudinal incision, as applied by Heinecke-Mikulicz on the 
pylorus and by me on the ureter, is applicable in any portion of the 
intestinal tract below the duodenum wherever the mechanical conditions 
will permit. 
The longitudinal incision or opening should be made in the middle of 
the convex surface—that is, equidistant from the two sides of the mes- 
entery, so as not to interrupt blood-supply by the division of large 
vessels in the intestinal wall. Free mobility of the loops of intestine 
and intact peritoneal covering are desirable conditions, but the latter 
is not absolutely necessary. In places where the intestine has no mes- 
entery and where there is a limit to the infolding or bringing into appo- 
sition of the convex surface or the surface of the intestine opposite the 
mesentery, as the caecum, extraperitoneal border of the rectum or 
flexures of the colon, there is a limit to the length of the longitudinal 
incision. In an organ so free and movable as the small intestine, I 
see no reason why I could not unite the convex surface to an extent 
of five or six inches, or more, if this would be desirable. In fact, I 
see no other limit than that of the length of the mesentery, the time 
required for suturing, and the length of the wound. It is evident that 
the length of the longitudinal wound should not be unnecessarily great. 
When there is no mesentery, and consequently only slight mobility, 
for folding in or apposition of the convex free surface of the intestine, 
or where the mobility is diminished or lost by diffuse inseparable adhe- 
sions, there is, of course, a limitation to the application of this principle. 
In one case of stenosis of the caecum from tuberculosis, with remittent 
attacks of pain from incomplete occlusion, in which I did not deem 
excision of the caecum advisable, I made this plastic operation, uniting 
transversely an incision of about four centimetres in length. The 
operation gave partial relief only, and a fecal fistula resulted, which 2 
FENGER: OPERATION FOR INTESTINAL STENOSIS. 
necessitated an iloo-colic anastomosis, which was followed by relief of 
the symptoms of the stenosis and left the fistula secreting mucus, as a 
rule, with, very rarely, some fecal matter. 
Tension in the united wound and lack of free fecal passage at the 
place of operation are, when the sutures are applied correctly, undoubt- 
edly the main cause of non-success—that is, of spontaneous reopening 
of the sutured intestine. 
This plastic operation, when applied to resection and circular suture, 
will enable us to avoid narrowing of the intestine by folding in of its 
wall at the place of suture (Fig. 1). If, for the sake of additional safety, 
it is deemed desirable to apply a second row of sero-muscular sutures 
at a distance of one-half centimetre from the first row, the advantage 
of having a larger amount of serous surface iu contact is counterbal- 
anced by the increase in size of the circular fold. The narrowing effect 
of a large fold can be overcome entirely by the plastic operation, be- 
cause we can make the longitudinal division long enough to secure a 
circumference of any size desired. 
The same principle is applicable when we wish to unite an intestine 
of small calibre end-to-end with one of large calibre. By longitudinal 
division of the smaller intestinal tube the line of union is easily made 
to correspond to that of the larger tube. If the lumen of the larger 
intestine is not deemed sufficiently wide to permit of so much folding in 
as is required, a longitudinal division is also here resorted to, until at 
last as large a line of union as we deem desirable is secured. 
In artificial anus, whether this be the result of a premeditated opera- 
tion or of an accident, where the mucosa of the intestine is finally 
united to the skin, it is commonly observed that the so-called spur forms 
a more or less complete obstruction to fecal passage from the proximal 
into the distal portion of the intestine. The spur, so to speak, leads 
the bowel-contents from the bowel out through the opening in the skin. 
The distal portion becomes small and retracted from non-use. 
The spur is formed by a semicircular fold or group of folds located 
opposite to the opening through the abdominal wall at the place of the 
bend of the opened intestine. This semicircular fold may increase so FENGrER : OPERATION FOR INTESTINAL STENOSIS. 
3 
as to extend entirely around the lumen of the intestine, thus becoming a 
circular fold, and is then located at the end of the proximal portion of 
the intestine close to the opening in the skin, through which it may 
protrude as a prolapse of the mucosa or wall of the proximal bowel. 
When this spur is well developed it may form, even when the intestine 
is loosened from the abdominal wall, an impediment to free fecal passage 
that frustrates simple transverse or longitudinal suture of the intestinal 
opening, and consequently necessitates resection of the loop containing 
the spur. 
As resection with subsequent circular suture is as yet an operation of 
some gravity, it would be an advantage to avoid resection and still 
overcome the stenosis and the influence of the spur with a more simple 
operation. That this can be done by application of the principle of 
the transverse union of a longitudinal wound I propose to show by the 
following case : 
A. T., male, aged fourteen years, an American of German descent, 
entered the German-American Hospital, for operation, in my service, 
on April 2, 1898. 
Family history. Father, mother, brothers, and two sisters living and 
healthy. One sister died of perityphlitic abscess. Grandparents, 
uncles, and aunts living and healthy, or cause of death unknown. 
Paternal grandfather died in old age of diphtheria. One paternal 
cousin had operation for appendicitis in 1894. 
The patient’s personal history was negative as regards disease or in- 
jury- 
Present illness. On the evening of March 22, 1897, the patient was 
seized with acute pain in the abdomen below the level of the umbilicus ; 
the pain was generalized, very severe from the first, and of a severe 
aching, griping character, and was accompanied by vomiting and 
diarrhoea* He had elevation of temperature, but no chill until the 
following day. The pain lasted throughout the night, but in the morn- 
ing it was not so severe and the patient walked about outdoors. At 
noon he had a chill and went to bed. Nausea and slight diarrhoea were 
present. Severe abdominal pain in the lower half of the abdomen came 
on at two o’clock the next morning and continued with remissions for 
two weeks, accompanied by daily elevation of temperature. 
A physician was called on March 24th, who made a diagnosis of ap- 
pendicitis. On April sth the perityphlitic abscess was opened in nar- 
cosis. Fecal matter, with pus, escaped from around the appendix at 
the time of operation. 
From this time until April 2, 1898, when I operated, a fecal fistula 
had existed, which has discharged a varying amount of feces daily. 
For the first eight weeks after the operation from one-fourth to one- 
eighth of the feces passed through the fistula and the remainder by the 
rectum. The rectal discharges were normal in color and occurred 
once daily. At the end of eight weeks the fecal discharge through the 
fistula decreased rapidly, so that it amounted only to a moistening of 
the dressings three times a day with fecal matter. About this time the 
wound was explored for gauze, which was supposed to have gotten into 4 
fexger: operation for intestinal stenosis. 
the intestine. After this exploration there was an immediate increase 
in the amount of fecal discharge through the fistula, which continued 
up to the time of operation. He has usually had about four to six 
evacuations daily through the fistula, varying from a drachm to three 
ounces, but ordinarily about one ounce. The feces were of normal color 
and soft, but not liquid. The amount of feces passed per rectum appears 
to be about the same as before the fistula was formed ; the character is 
normal; the bowels are regular and there is no tendency to diarrhoea. 
Relief from pain immediately followed the opening of the peri- 
typhlitic abscess and he has felt well ever since, Avith the exception of 
a few hours after the operation. 
Operation, April 2, 1898. After the usual preparation, liquid diet 
and irrigation of the bowels through the fistula in another room, with- 
out using a rubber tube to push the spur back or down, he was brought 
to the operating-room. When he was put upon the table feces welled 
out. There were present at the operation the doctors from the Poly- 
clinic. Drs. Haiselden and Buford assisted, and Dr. Gottschalk ad- 
ministered the ether. 
. The fistula was located in the right inguinal region, an inch to an 
inch and a half from Puiipart’s ligament, or from the anterior superior 
spine of the ilium. The opening was six centimetres in circumference, 
two centimetres in diameter, and would admit the little finger. The 
mucosa of the intestine was united to the skin, that is, the fistula was 
labiate. The mucosa bled when the finger was introduced. A tongue- 
shaped flap of mucosa, one centimetre square, protrudes when he strains. 
It comes out of the upper, outer corner of the fistula, and can be easily 
replaced. The fistula is surrounded by excoriated skin for an inch or 
more (Fier. 2). 
Fig. 2. 
Prolapse of tongue-shaped mucosa. Opening passable for the little finger. Dotted line 
indicates incision for cutaneous flap. 
The fistula Avas now circumcised, one centimetre and a half from its 
border, through the skin, subcutaneous tissue, and abdominal muscles, 
down to the transversalis fascia (Fig. 2). This circular flap, like a 
collar, Avas loosened and closed tightly by a continuous silk suture so 
that none of the intestinal contents could pass out. 
The abdomen Avas then disinfected and clean covers put on the table 
and the patient. 
I now opened the peritoneal cavity one inch medial to and above the 
fistula, using great care to avoid adherent intestine. The omentum 
met Avith at first Avas ligated in portions. The isolation of the loop PENGEE : OPERATION FOR INTESTINAL STENOSIS. 
5 
with the fistula was relatively easy. It was found to be a loop of small 
intestine, and was surrounded by gauze sponges, freed from adherent 
omentum and held aside out of the abdominal wound while search was 
being made for the csecum and appendix. The wound was packed 
with several sponges, the parietal peritoneum united to the skin, the 
branches of the inferior epigastric artery ligated, and the incision pro- 
longed up and down in the sheath of the rectus muscle. 
The caecum was found to be free from adhesions and the appendix 
was adherent to the caecum. The end of the appendix was dilated, 
fluctuating, and contained a fecal concretion. 
The appendix was amputated and the stump buried under a musculo- 
serous circular flap. 
I now proceeded to operate on the fecal fistula, which was found to 
be located two feet above the caecum. The loop of the ileum containing 
Fig. 3. 
Proximal end of gut incised through prolapsed mucosa ; spur seen on mesenteric side, 
within gut. 
the fistula was pulled well out of the wound and surrounded by gauze. 
The loop was emptied and ligated by means of gauze strips, two to three 
inches on each side of the fistula (Fig. 3). The adherent omentum 
was dissected off from the intestine, which necessitated only a few liga- 
tures. The abdominal-wall flap was then cut oflf from the border of 
the fistula. 
The fistula appeared as a round or oval opening one-half to an inch 
in diameter on the convex surface of the ileum, half to three-quarters 
of an inch from the mesenteric border on each side (Fig. 3). The 
tongue-shaped flap of mucosa was found to be part of a circular fold 
hanging down from the proximal border of the fistula, continuous with 
the spur, and forming with this a circular prolapsed and invaginated 
valve or flap. 
It was evident that a simple union of the fistulous opening either in 
a transverse or longitudinal direction would not do away with the 
stenosis caused by this ring-shaped valve of the mucosa, and conse- 6 
FENGER: OPERATION FOR INTESTINAL STENOSIS. 
quently would not remove the impediment to the passage of feces at 
this point, because this ring of mucosa would protrude into the lumen 
of the intestine and perhaps be the beginning of an invagination, or 
would at times at least impede fecal circulation. 
Fig. 4. 
Wound in ileum held out, showing spur, viz.: A counter fold or group of folds of mucosa. 
Line of incision 1 inch down into distal (smaller) portion of ileum. 
I believe that the spur or circular valve, by causing a disturbance 
of fecal circulation, is the cause of the common failure of permanent 
closure of the fistula following simple suturing of the intestinal opening. 
The fistula reappears in a week or two and reopens because of the 
spur which remains. 
I therefore decided to overcome the effect of the spur by the follow- 
ing plastic operation on the intestine : 
1. A longitudinal incision at the convex border of the intestine one 
inch in length in the proximal end of the intestine through the tongue- 
shaped valve, up into the normal intestinal wall above it (Fig. 3). 
Fig. 5. 
The whole of incision, viz.: the longitudinal wound in the ileum at middle of convex (oppo- 
site to mesentery) border. 1 inch up, 1 inch'down ; width of fistula % inch =2% inch, a 
lower and a' upper corner to he united by a guide suture left long. 
2. A longitudinal incision, one inch long, into the distal or narrower 
portion of the intestine below the spur, thus making a longitudinal 
wound two inches in length on the convex border of the intestine 
(Fig. 4). As the original fistulous opening was two centimetres in 
diameter, the wound would be about three inches in total length. Upon 
making the incision at the upper end of the wound I saw a Peyer’s 
patch. FENGEE : OPERATION FOR INTESTINAL STENOSIS. 
7 
The spur formed a circular valve of two or three parallel folds of 
mucosa, half au inch broad, most pronounced on the mesenteric side, 
extending around the entire circumference of the intestine, but smaller 
on the convex border (Fig. 5). 
Fig. 6. 
Continuous suture. Lies through whole thickness of wall, aided by the guide suture. 
3. Transverse union of this longitudinal wound (Fig. 6). 
a. Suture a-a! (Fig. 5) united the upper and lower corners and was 
left long for traction, dividing the wound into two transverse halves 
with the suture in the middle. 
b. A continuous silk suture through all the layers of the intestine 
(Fig. 6). 
Fig. 7. 
Sero-muscularis continuous suture to bury the preceding suture. 
c. A continuous serosa-muscularis suture, one centimetre outside of 
the former. 
d. A second continuous serosa-muscularis suture to bury the former 
(Fig. 7). 
4. Disinfection of the sutured loop with 1 :1000 sublimate solution, 
and removal of the gauze ligatures around the loop of intestine. 8 
FENGER: OPERATION FOR INTESTINAL STENOSIS. 
5. Removal of the sponges and examination of the abdomen for hem- 
orrhage. 
6. Step sutures of the abdominal wall. 
7. Gauze drain down to the appendix and over to the sutured loop 
of the ileum. 
8. Injection of two quarts of physiological saline solution into the 
rectum. 
The operation lasted three hours and a half. At its close the 
patient’s pulse was good ; no shock, 
7.30 p.m. Gaseous distention of the abdomen. A little gas escaped 
after insertion of the rectal tube. 
April 3d. Patient had a small dark-green and very thin bowel move- 
ment. Throughout the day he had considerable trouble on account of 
gaseous distention, for which injections of warm water and peppermint 
were made, but little gas passed. Temperature 97.4° to 100.2°. Pulse 
120 to 130. 
4th. A small amount of gas passed after injection of peppermint water. 
During the day he vomited several times, dressings were changed, half 
an ounce of bloody fluid, with some bright yellow pus, followed the re- 
moval of the packing. A drainage-tube was introduced. Temperature 
98.4° to 100°. Pulse 100 to 108. During the day he had two small 
bowel movements. 
sth. He passed considerable gas and had two dark green, thin bowel 
movements. Temperature, 99.2°. Pulse, 90. 
6th. Slept well last night. Temperature 99.6°. Pulse 76. The 
drainage-tube was removed, half an inch cut off, and reinserted. Dress- 
ings were dry. 
7th. Temperature 99.6°. Pulse 66. A large bowel movement fol- 
lowed the use of euemata. 
Bth. Temperature 99.4°. Pulse 56. Tube removed. 
11th. Temperature 98.4°. Pulse 68. He has no pain. Eats and 
sleeps well. 
24th. Only a granulating surface remains. The function of the 
bowels is normal. 
October. Patient remains well. 
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