A CONTRIBUTION TO HEPATIC SURGERY, WITH A SUGGESTION FOR RENDERING A PORTION OF THE LIVER EXTRAPERITONEAI, BY L. McLANE TIFFANY, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND. EXTRACTED FROM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, JUNE, 1888. Extracted from the American Journal of the Medical Sciences for June, 1888. A CONTRIBUTION TO HEPATIC SURGERY, WITH A SUGGESTION FOR RENDERING A PORTION OF THE LIVER EXTRAPER1T0NEAL. By L. McLane Tiffany, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND. In the following pages I have ventured to place in the same category the two apparently very dissimilar pathological conditions, abscess of the liver and stone in the gall-bladder, because a cure was wrought in both instances by operative measures in the main identical. The impor- tant part of each operation was the shutting off of a portion of the liver by suture from the general cavity of the belly, so that treatment could be directly applied irrespective of the neighboring but not entirely investing peritoneal sac. Case I. Abscess of liver following dysentery; laparotomy; suture of parietal peritoneum to liver: drainage and irrigation of abscess cavity; cure.-H. B., male, aged twenty-four years, American parentage, a winner of athletic prizes (long distance runner), gave the following history. October, 1884, he suffered from acute dysentery which greatly debilitated him. March, 1885, he started on a Southern trip, but returned in a month, dysentery having reappeared. In July he went to the mountains, deriving benefit, and in August to the seashore, but derived no advantage to his health. During the following winter his bowels were irregular as also during the spring, appetite was capri- cious and exercise impossible owing to general lassitude. He was now told by his physician that he suffered from congestion of the liver. During the summer and autumn of 1886 bowels, appetite, and general lassitude did not improve, pain in the right shoulder was occasionally noticed, and two or three chills, at irregular intervals, occurred. I first saw the patient January 20, 1887. His general aspect was scarcely that of a man who had been ill twenty-seven months. His complexion was pale, lips pink, in walking the trunk was held stiffly erect, and when seated a pillow was always placed behind the back for support. Measurement showed the base of the right chest slightly 2 TIFFANY, larger than the left. The liver did not project below the ribs, but the respiratory murmur was less marked'in the lower right chest than on the left side. Percussion revealed nothing. Heart was normal. Exami- nation of urine, as well as rectal exploration by sight and touch, was negative. The bowels were usually constipated, and the stools rarely of natural color, clay colored often: blood was sometimes seen, so it was said, but I found none though careful search was made. Temperature normal in the morning, but about one degree higher in the evening. Pulse was never under 116 per minute. Liver abscess was strongly suspected, and during the following two or three weeks the liver appeared below the ribs while respiratory sounds in the right chest were not heard as low as in the left chest, being re- placed by dulness. Pain in the right shoulder was marked, and measure- ment of right base showed increase compared with left of one-fourth of an inch. A diagnosis of liver abscess in the concavity of the diaphragm was made, and aspiration advised. Dr. Salzer, who had attended the patient some months previously, met me in consultation, confirmed the diagnosis, and concurred in the proposed treatment. March 9. I aspirated between the ribs in the anterior axillary line nearly on a level with the nipple, that being the place where the respi- ratory murmur ceased. I selected this point because near the collection of pus, and I was unwilling to pass a needle for diagnostic purposes through the whole liver thickness. I thought also that the pleural mem- brane could be disregarded. Nearly a quart of brown, highly charac- teristic, inodorous pas was withdrawn; the patient's condition was rendered much more comfortable. Improvement was of but short duration, one week later the patient had a well-marked rigor, followed by sweating; the liver descended, the line of respiratory murmur ascended, the pulse 130 per minute, etc. Radical measures were clearly indicated. I chose the peritoneal route rather than between the ribs, as giving more room and better drainage. Present, Drs. Salzer and Martin. Operation, March 19th, with antiseptic precautions, except the spray, mercuric bichloride being the antiseptic. An incision three inches long was made just below, and parallel to, the right costal cartilages, and carried down to the peritoneum ; hemorrhage being arrested, this mem- brane was opened for a distance of two inches, and the liver exposed; it was not adherent. Slight traction on each lip of the wound caused the edges of the peritoneum to open widely, showing an oval area of liver surface, one by two inches. With a fine needle and silk I sewed by close continuous suture the peritoneum edge and liver surface together. The general cavity of the peritoneum was thus shut off from my wound, and I had a button-hole of extraperitoneal liver, so to say, one by two inches, CONTRIBUTION TO HEPATIC SURGERY. 3 at my disposal for operation. Pressure by sponge arrested the slight oozing from liver tissue where sewn. An aspirator needle was passed into the exposed liver, and directed toward the abscess; resistance ceased after traversing about three inches of hepatic substance and pus flowed. Using the canula as a guide, the abscess was freely opened, about two quarts of brown pus were evacuated, and the cavity freely irrigated, pressure arrested bleeding from the liver tissue. A large drainage tube was placed in the wound, and an iodoform gauze dressing adjusted. It was noted that flakes of white pus were mixed with the usual brown liver pus, as though acute inflammation was present, possibly set up by the tapping (?). The dressings were changed as soiled, and the abscess cavity irrigated. All went well, fever disappeared, pulse became less rapid and more strong, appetite improved. Convalescence was apparently established. Two weeks later pus ceased to appear, perfectly clear bile in large quan- tity replacing it, and a marked change for the worse was noticed in the patient. The bowels filled with gas, the appetite failed, the tongue became less moist, the complexion mottled and " dirty." I gave dried ox-gall in capsules, with the effect of somewhat improving the symptoms, but it was evident that unless the bile would flow into the intestine my patient's days were numbered. I believed that a large bile duct was opened, possibly by pressure of the drainage tube, so I replaced the large by a small tube, no good resulted. An aseptic condition of the wound was present during the continuance of the biliary flow, and bile, as an antiseptic dressing, naturally suggested itself for future trial. I then withdrew the tube, dressed with gauze (iodoform), cotton, a bandage, and let matters take their course. In a week discomfort was complained of, so I passed a probe along the track of the tube, allowing reddish-brown pus to escape, but little bile flowed. This was continued every few days for three weeks, when I replaced a drainage tube in the abscess cavity ; no bile appeared, and convalescence was definitely estab- lished. It is now more than one year since the operation, the patient continues in perfect health, and follows his usual avocation. Case II. Laparotomy; suture of parietal peritoneum to liver; gall- bladder opened through the liver; extraction of calculi; recovery.-This prtient I saw with Dr. George L. Wilkins, whose full notes are appended. The description of operative measures is by my own pen. It will be seen that the route by which the cavity of the gall-bladder was reached is novel; it remains for the future to show under what circumstances it should be followed. Mrs. N., aged thirty, married, mother of several children ; previous health good; has had, since about the first of August, 1887, frequent 4 TIFFANY, attacks which have presented the clinical history due to the passage of biliary calculi. Has had frequent paroxysms of pain, recurring at in- tervals ranging from one to two weeks, of variable duration, and usually sudden in their onset and disappearance. The pain always started from the right hypochondriac region, extending toward the epigastric region, the right shoulder and back. Jaundice always followed the attacks of pain. Urine showed the presence of bile, and the feces were clay colored. Vomiting usually followed the attacks, and throughout dyspeptic symp- toms predominated. Palpation and percussion showed pain and tume- faction in the right hypochondriac region. Gall-stones were found from time to time in the feces. After exhausting all of the usual measures of treatment, including the so-called bile solvents, and despairing of the life of the patient, operative treatment was proposed and accepted. Condition on the day of the operation: small, frail woman, consider- ably emaciated; skin and conjunctiva considerably icteric; pulse 96 and feeble; temperature 99.6°. In the right hypochondriac region a tumor could be felt which was painful to the touch, movable, its position approaching the median line when patient was placed on her left side, and following the respiratory movements of the liver. Operation per- formed at 12.45, January 17, 1888, under strict antiseptic precautions, except the spray ; room well heated ; ether used as anaesthetic. Operation.-A vertical incision two inches long was made over the induration in the right hypochondriac region. The peritoneum was exposed, and, bleeding being arrested, was opened to the same length as the skin wound. The liver came into view; digital exploration failed to detect the gall-bladder. The incision through the abdominal wall was extended two inches downward, permitting free manual and ocular examination. It was found that the intestines were adherent to the under surface of the liver and to the gall-bladder. This latter viscus, felt through the adherent bowels, appeared to be globular, an inch and a half in diameter, and two or three inches from the edge of the liver. I did not think that if the adhesions were torn through it would be possible to sew the gall bladder to the skin, so deeply did it lie beneath the liver. I did not make out a stone impacted outside of the gall-bladder. The liver was much enlarged, and the hardness felt through the belly walls cor- responded to what I believed to be the situation of the gall-bladder. I had intended to operate in the usual way draining the bladder externally, but in view of the conditions found, and of the excellent result obtained by stitching the liver and peritoneum together in the abscess case already stated, I operated as follows: A slender, hollow needle was passed directly through the liver from above downward into the gall bladder, on aspirating perfectly clear fluid entered the body of the syringe; I considered that if adhesion prevented the gall-bladder from projecting beyond the liver edge the same adhesions would prevent CONTRIBUTION TO HEPATIC SURGERY. 5 extravasation into the peritoneal cavity ; so I sewed the parietal perito- neum to the upper surface of the liver, making a "buttonhole" li x 2 inches, closing also the rest of the peritoneal incision, and then using the needle, which remained in situ as a guide, I cut directly through the thickness of the liver into the gall-bladder. I made the incision of such a size that my finger would fill it. A gush of blood followed the use of the knife, and at once withdrawing it, I thrust my left forefinger into the wound completely arresting hemorrhage; the end of my finger recog- nized several stones, showing that the sought-for locality was reached. I did not move my finger for three minutes, by which time no hemor- rhage followed its withdrawal. I extracted with forceps thirteen calculi, two others seemed to be in or near the duct, these broke in fragments during removal; up to this time no bile was seen, but shortly after the last two stones were withdrawn a green stain was noticed on the sponges. I considered this to indicate that the passage of bile into the bladder hitherto prevented, evidenced by the clear mucus, was now free. A rubber drainage-tube was left in the gall-bladder, and the abdominal wound closed save where the tube passed. Iodoform gauze, cotton, and a bandage completed the dressing. January 17. 6 P. M., pulse 88 ; temp. 99.6°. No vomiting or pain. Opium gr. j, every three hours. Fluid nourishment. 18/A 12 m., pulse 108; temp. 100.7°. Several slight paroxysms of pain during the night. No vomiting or abdominal tenderness. Urine shows bile. Free discharge of bile through wound. 6 p. m., pulse 100; temp. 100.5°. No vomiting, pain, or tenderness. Dressing saturated with bile. 19/7t. 11 a. m., pulse 88; temp. 99.5°. No vomiting, pain, etc. Con- tinued discharge of bile through wound. Dressings clean. Discon- tinued opium. 6 p. m., pulse 84; temp. 99.5°. No vomiting, pain, etc. Regurgitation of small quantity of bile per mouth. 20/7t. 11 a.m., pulse 88; temp. 98.5°. Dressing only slightly soiled. 5 p. m., pulse 82; temp. 100°. 21s7. 12 m., pulse 100; temp. 99.5°. Depressed, anxious coun- tenance. During the night of the 20th several chills followed by bilious vomiting; urine free and contains bile. No abdominal tenderness, pain, or tympanites. Dressing slightly soiled by bile and blood. No odor. Drainage tube removed. Ordered calomel and brandy. 6 p. m., pulse 112 ; temp. 99°. Vomited once since morning. Continued restlessness. 22d. 9 a.m., pulse 110; temp. 100°. No vomiting or pain. Since last evening the operations showing presence of bile. Urine assuming a lighter color. Jaundice disappearing. Quinine, two grains every second hour. 23d. 10 a.m., pulse 108; temp. 100°. 5 p.m., pulse 92; temp. 99°. No vomiting, etc. 24i/i. 10 a.m., pulse 92; temp. 99°. 5 p.m., pulse 84; temp. 98.6°. Daily bilious operations. 6 TIFFANY, CONTRIBUTION TO HEPATIC SURGERY. 25th. 1 p.m., pulse 84; temp. 99°. Cheerful. No pain or vomiting. Two operations of greenish-yellow color. Discharge from wound healthy. Continued quinine. 26th. 11 a.m., pulse 78; temp. 98.5°. No pain or vomiting. Two bilious operations. Discharge through wound of viscid mucus slightly tinged with bile. 21th. 11 a.m., pulse 76; temp. 98.5°. No pain, etc. Operation show- ing presence of bile. 28th. Pulse 72; temp. 98.5°. No operation, vomiting, or pain. Night of January 27th, profuse sweating followed by chill. Discharge through wound of viscid mucus and bile. 3(M. Pulse 78; temp. 99°. Free discharge of bile through fistulous opening. Ordered small doses of mag. sulph. to secure daily movement of the bowels. 31st Pulse 78 ; temp. 98.8°. Feces show presence of free bile. Urine free from bile. Dressings soiled with bile. Jaundice almost entirely gone. Pain, tenderness, and slight enlargement of parotid gland on left side. February 2. 12 m., pulse 78 ; temp. 98.5°. Dressings slightly tinged with bile. Daily movement of bowels, feces loaded with bile. Urine normal. Pain and tenderness of parotid gland subsiding. Patient cheerful and bright. Removed sutures. Perfect union of incision except small fistulous opening. bth. Pulse 72 ; temp. 98.5°. No discharge through wound. Free bilious evacuations. Pain in parotid gland almost entirely gone. 17£/t. Pulse 78; temp. 98.5°. Perfect union of wound. 24d,h. No jaundice. Improved in flesh and strength. Gradually resuming her household duties. No pain or enlargement in right hypo- chondriac region, etc. The above cases seem clearly to indicate that liver hemorrhage, so much dreaded hitherto, is amenable to pressure applied directly upon the bleeding surface, in that regard resembling the kidney, the subject of so much brilliant surgery within the past few years. The method adopted of opening the parietal peritoneum, separating the edges, and sewing them to the liver, shuts off a corresponding area of that viscus from the general peritoneal cavity, and exposes it to the surgeon for treatment as any other external surface of the body. In stab or gunshot wounds of the liver, it is easy to see how this procedure affords a means of arresting hemorrhage, and provides a method of con- tinuous drainage; so also in contusion or crush of the liver, and other pathological conditions not necessary to enumerate. So easy is the opera- tion of performance, and so rapidly is a portion of the liver rendered extraperitoneal, that it may even be of use as a diagnostic measure.