J AN EXPERIMENTAL STUDY 
— OF — 
„ ' 
Intestinal Anastomosis 
WITH SOME PRACTICAL SUGGESTIONS ’ 
—AS TO A— 
MODIFIED TECHNIQUE. 
BY 
A. V. L. BROKAW, M.D, 
OF ST. LOUIS, MO. 
Reprint from Weekly Medical Review, Aug. 17, 1889. AN EXPERIMENTAL STUDY OF INTESTINAL AN- 
ASTOMOSIS—WITH SOME PRACTICAL SUG- 
GESTIONS AS TO A MODIFIED 
TECHNIQUE. 
BY A. V. L. BEOKAW, M.D., 
Demonstrator of Anatomy in Missouri Medical College; Assistant to 
the Chair of Surgery and Senior Assistant Surgeon, 
St. John’s Hospital, St. Louis, Mo. 
Until Nicholas Senn gave us the results of his labors 
in the field of intestinal surgery, the prospect for great 
success in such operations was rather unpromising; but 
all agree now, I think, that he has reduced some of the 
most difficult problems in intestinal work to a basis of 
absolute simplicity. Operations which heretofore con- 
sumed one, two or more hours, even in the hands of 
surgeons noted for their rapidity and skill, can now, by 
a knowledge of the technique of Senn, or the more re- 
cent modification suggested by Abbe of New York, be 
completed in a very few minutes. 
The intestinal anastomoses formed by the use of de- 
calcified bone-plates as used by Seun, and the catgut 
rings of Robt. Abbe are both very excellent methods. 
After experimenting with the methods mentioned, I be- 
lieve I have devised a far more simple technique, and 
offer as a substitute, rings of unperforated rubber tub- 
ing, which, if prepared in the following manner, will 
greatly simplify the process of forming intestinal an- 
astomosis: 
Unperforated drainage tubing of a diameter less than 
one-fourth inch is selected. For most work the white- 
ribbed tubing of one-seventh or one fifth inch in dia- 
meter is preferable. Of this a section is taken some 
three inches long, or even longer, according to the size 
of the opening desired. Through the lumen of this 
section of tubing are passed several strands of dried jun- 
iper catgut; these strands are left to protrude for some 
distance from the extremities of the tubing to faciliate 
the process of tying. We now have an elastic ring 
which is oval and maintains its shape until the catgut 
Intestinal ring made of a piece of rubber tubing. 
Intestinal rubber ring made of two pieces of tubing. 
Strands of catgut ( ) within the Tube to which tie the approximation thread. ( ) 
Clamps of No. 12 copper wire covered with rubber tubing. strands within the tubing give way. It then straight- 
ens out and passes from the bowel. Four to six small 
slits or openings are made equidistant in the sides of 
the ring and through these are passed fine silk; these 
ligatures are then caught and fastened to the strands of 
catgut within the ring, as described above. This avoids 
the formation of knots and irregularities and aids the 
ready throwing off of the rings when the catgut is ab- 
sorbed. It now only remains necessary to thread the 
needles. If catgut apposition-threads are used—and 
I find that with these, the ring comes away some days 
earlier than when silk threads are used—it is only 
necessary to attach the apposition strands direct to the 
rubber tubing, thus avoiding the trouble of attaching 
the threads, if silk be used, to the gut-strands within 
the ring. To avoid tangling of the threads and un- 
necesary waste of time, I have found it convenient to 
place the ring thus finished upon an anteseptic towel 
or flat sponge, keeping the needles apart. 
With two such rings I find the operation of intestinal 
anastomosis extremely easy. The advantages claimed for 
rings so prepared are, that on compressing laterally the 
ring, its introduction through the intestinal opening,even 
though the latter be quite small, is very easy, and the ring 
sorbed by the action of the intestinal fluids upon them. 
The simplicity in the preparation of these rings is a 
strong plea in their favor, for, in case of emergency, 
they can be made in a few moments during the opera- 
tion. Senn’s plates are difficult to prepare and the 
opening is sometimes rather small. The catgut rings 
of Abbe are most excellent, but I find that to give them 
a fair preparation requires too much trouble and time. 
The rubber rings cannot kink or curl up, but on absorp- 
tion of the catgut strands within the rings, they become 
straight and offer no obstruction in their passage. Bone- 
plates, when not soon absorbed, may block up the in- 
testinal opening by becoming impacted, and an une- 
qual absorption of catgut rings might form an obstruc- 
tive meshwork at the point of anastomosis. 
Before opening the gut, it is necessary in most all 
cases to apply clamps, or a temporary elastic ligature 
distally and proximally to prevent fecal extravasation. 
Very small drainage tubing, one-eight or one-fourth 
inch in diameter, is frequently used for the purpose by 
passing it through the mesentery and tying it around 
the intestine. This answers very well, but an inexpen- 
sive clamp, which may be used with advantage, may be 
prepared in this manner: Six or seven inches of No. 
immediately resumes its oval shape within the intes- 
tine. There is no tendency to a lateral falling togeth 
er of the wound-margins or lessening of the aperture, 
which might occur by the softening of catgut rings. 
From numerous experiments on dogs, I find that the 
resulting aperture is all that could be desired. The 
rubber ring is thrown off per viam naturalem as soon as 
the catgut strands within the tube are softened and ab- 
12 copper wire are covered with unperforated rubber 
drainage tubing of small size. The extremities of tub- 
ing over lapping the ends of the wire are ligated and 
the rubber-covered wire is bent upon itself. The clamp 
is applied by slipping it over the free margin of the in- 
testine, at the same time pushing the lower blade through 
the mesentery, fairly close to its junction with the in 
testine. The blades are made perfectly parallel and an elastic band or ligature is thrown around the ends. 
This little appliance is very simple and has several ad- 
vantages; it holds the intestinal walls evenly together, 
aiding the assistant in holding securely the intestines 
while the rubber rings are being introduced and tied 
in position. 
The manner of applying the rings in forming an in- 
testinal anastomosis is exceedingly simple. Compress 
the ring, pass it into the lumen of the bowel or stomach, 
as the case may be, pass the threads at the end of the 
oval first and then the lateral threads. Now make 
slight traction to ascertain whether the ring rests well 
in place; pass the second ring in the same manner, ap- 
pose and tie. 
Scarification of the marginal serous surface as sug- 
gested by Senn is of undoubted value, since it increases 
plastic exudation and creates greater promise of union. 
Illustrating an anastomosis after enterectomy. 
A few Lembertsutures at several points add to the safe- 
ty; this can be done after tying the apposition threads. 
After many experiments, I think I have devised a 
method of treatment, which may in some cases of gun- 
shot injury of the intestines be of value. If the wounds 
be not too close together, especially where a stenosis 
might follow suturing, the method to be explained 
seems to answer the purpose admirably, as proven by 
experimental studies. If the wounds are wide apart 
each one should be dealt with separately. The mar- 
gins of the wound should first be carefully trimmed 
with scissors; the oval ring, selected for the purpose, 
should be of good length, the aperture about two and 
one-half inches. Six threads of apposition should be 
used with this ring, so arranged that when tied they 
will hold the oval ring bent evenly on itself. One thread 
at each end of the ring and two on each side are desir- 
Illustrating an anastomosis after an enterectomy. Gunshot wound. 
Ring bent double and sutured in position. 
able. The ring is now introduced into the bowel and 
doubled upon itself, then the threads are tied, begin- 
ning with the end strings and afterwards with the lat- 
eral. The addition of a few Lembert sutures adds to 
the security. 
The apparent flexion of gut thus produced will be 
found to have as great, if not greater, lumen at the 
point of flexure than the neighboring parts of the in- 
testine. Other isolated wounds may be treated in the 
same manner. If two wounds are in the same loop of 
intestine, I would suggest the use of two ordinary sized 
rings, the trimming of the wound edges and the form 
ation of anastomosis. When more than two wounds 
are found close together, an anastomosis by lateral 
apposition, after excising the damaged portion of the 
bowel, would be far better than attempting the classical 
circular enterorrhaphy. 
These principles of operative procedure may be ap- 
plied to a great number of similar cases, e. g., to per- 
forated typhoid ulcerations of the bowels, etc. 
To sum up the whole, the substitute offered seems to 
be in every respect an improvement. The great trinity 
of attributes in surgery—especially abdominal surgery 
—is simplicity, safety, rapidity, and the technique pro- 
posed in this paper, I believe, embraces them all. 
Note I.—Rings made from two equal sections of tub- 
ing pass from four to six days earlier than those made 
of a single section; vide illustrations of rings. 
Note II.—In my experimental operations on 12 dogs, 
Ring in the intestine before tying. 
but one dog died, and this death was not the direct re- 
sult of the operation, for the dog did well until the 6th 
day, when he tore out the abdominal sutures; as a re- 
sult, the intestines were extruded and became covered 
with dirt. This was not noticed for probably several 
hours; when it was discovered, I replaced the viscera 
into the abdominal cavity after washing them thoroughly; 
the dog died four hours later of peritonitus and shock. 
Note III.—In the operation described above for treat- 
ment of gunshot wounds with a single ring, there may 
be some tendency to eversion of the margin of the 
bowel at the point of flexure ; to prevent this I find that 
a single cat-gut suture passed through the margins of 
the wound at the point of flexion is all that is necessary. 
The suture need not be drawn tight enough to bring the 
wound-margins together ; I usually leave them about a 
quarter of an inch apart. This step should always fol- 
low the introduction of the ring. 
Note IV.—In my third series of experiments upon 
seven dogs, the rings used were made of from four to 
six equal sections of tubing in the manner described. 
This modification of the original ring, made of single 
or double sections of tubing, is probably of decided 
value, as the small segments come away earlier. In a 
gastro enterostomy made Aug. 3, some of the segments 
of the rings used were found on the ninth of August. 
The closure of a large opening in the free surface of the 
bowel (size of a half-dollar) may be made in five min- 
utes, and with practice in less time.