THE USE 
OF 
SEGMENTED RUBBER RINGS 
IN 
Intestinal Anastomotic and other 
Operations. 
9 BY 
A. V. L. BROKAW, M.D., 
Demonstrator of Anatomy, Missouri Medical Medical Depart- 
9Unt, State Vr/^ersity; • 
Senior Assistant Surgeon, St. John's Hospital, 
St. Lovis, Mo. 
tRegrintyf'from, the International Journal of Surgery, 
* ' For November, 1889. 
Press of E. P. Coby & Co., 93 & 95 William Street, 
New York. THE USE OF SEGMENTED RUBBER RINGS IN INTES- 
TINAL ANASTOMOTIC AND OTHER OPERATIONS. 
A. V. L. Brokaw, M. D.,* 
Demonsti ator of Anatomy, Missouri Medical College, Medical 
Department State University, Senior Assistant Surgeon 
St. John's Hospital, St. Louis, Missouri. 
The success which follows all operations requiring 
abdominal section largely depends upon time, and 
this is especially true when the intestines are being 
dealt with. When there are conditions indicating- 
resection, such as certain gunshot injuries, gangren- 
ous hernias, neoplasms, or other morbid processes, 
the operations which can be performed with the least 
loss of time, and which experiment has proven to 
give the best results, should be selected. When the 
conditions demand resection, the methods of lateral 
approximation or circular enterorrhaphy are, without 
doubt, superior to all other methods ; if for no other 
reason than the safety, simplicity and rapidity of their 
performance. I was led by the articles of that master 
Surgeon, Nicholas Senn, to conduct a series of experi- 
ments in the field of intestinal surgery. My great 
object in experimenting was to simplify and improve 
the method of Senn in one particular, viz., the rapid 
preparation of a substitute for his bone plates in case 
of emergency. In the course of experimenting I 
devised an intestinal ring which has proven highly 
satisfactory in performing all the anastomotic 
operations and also such operations as gastrostomy, 
* Paper read before " St. Louis Medical Society," September 91 1SS9 
Reprinted from the International Journal of£ 2 
cholecystotomy, duodeno-cholecystotomy, jejuno- 
cholecystotomy, and even circular entero rrhaphy. 
Fig 1. Four Segment Ring. 
The rings used by me in these experiments are 
very simple in their construction, so that a number 
of them may be made in a few minutes, during the 
operation if need be. All that is required is some 
white ribbed rubber tubing, from one-sixteenth to 
one-eighth inch in diameter ( i. e. of lumen) : a 
section three or four inches in length ( according to 
the aperture desired) is cut into from four to eight 
equal parts, and heavy strands of catgut arc passed 
through the lumen of these pieces of tubing. The 
ends are then tied sufficiently tightly to bring the ends 
of all the segments closely together, thus forming an 
oval ring. The knot is tucked snugly into the lumen 
of the tubing. To this ring are attached four to six 
silk apposition threads, each being twelve to four- 
teen inches long. These threads are tied to the cat- 
gut strands which hold the sections of tubing 
together, in this manner : The rubber segments are 
slightly separated and the silk apposition threads 3 
tied firmly around the catgut strands within the 
tubing ; the knots are then pushed into the tubing. 
It is now only necessary to attach the needles to the 
apposition threads, and the ring is ready for use. 
(see Fig. 1, 2, 3.) 
Fig. 2. Four Segment Ring. 
Fig. 3. Sectional View. 
Another method of making the rings, and one 
which requires but a trifle more time, is as follows : 
pass a heavy strand of raw gut ( No. 2 or 3) contin- 
uously through the segments of tubing several times ; 
make traction upon the ends of the catgut sufficiently 
to approximate the ends of the segments and, as 
a last step, push the ends of the catgut into the 
tubing. It will be found that a ring so fashioned 
will have a better surgical finish after tying the 
apposition threads between the segments. There 
can be no slipping or displacement, and the ring will 
maintain its perfect form, until the catgut within 
the lumen is absorbed, or gives way as a result of 4 
the action of the intestinal fluids. Segments of rings 
made as described, were passed as early as the fifth 
day in one of my experiments. The aperture of the 
rings used in these operations varied from one inch 
to one and three-fourths inches. 
With this simple device, the operation of forming 
an anastomosis is very easy : Thread ordinary No. six 
straight darning needles to the apposition threads, 
and place the rings upon a flat sponge or towel to 
prevent tangling, or what is better still, after thread- 
ing the needles, stick each equidistant into the 
tubing or a wide cork, and the delay caused by tang- 
ling of the threads in handling will be avoided. The 
application of the ring is made in this manner : com- 
press the ring, pass it into the lumen of the bowel or 
stomach through the opening previously made, pass 
the threads at the end of the oval first, through the 
intestinal wall from within outward, then the lateral 
threads; make slight traction to ascertain whether 
the ring rests well in place, and proceed to the 
second. Apply this in the same manner, oppose, and 
tie the apposition threads, after scarification of the 
marginal serous surfaces as suggested by Senn. This 
briefly is the technique of applying the segmented 
rubber rings in the anastomotic operations. It is of 
extreme value, in cases where it can be done, to 
utilize the omental grafts. The procedure requires 
but very little time and adds security to the 
operation. 
With two segmented rubber rings such as have 
been described, the operation of circular enterorr- haphy may also be easily performed as follows : The 
diameter of the gut ascertained, two rubber rings are 
made of sufficient size to be adjusted to the lumen of 
the bowel operated upon. Care should be exercised that 
the rings used are not so large as to press too much 
upon the delicate mucosa, or to overstretch the bowel 
after introduction, as a local gangrene from pressure 
is apt to follow. The rings are introduced into the 
bowel at the point of section of the gut, and the ap- 
5 
Fig. 4. Manner of applying Rings in Enterectomy. 
position threads are passed through the intestinal 
wall less than one-half inch from the margin of the 
divided bowel. This procedure is repeated with the 
second ring, and the overlapping edges of the intes- 6 
tine are dealt with thus : the distal end is invagi- 
nated, and the end of the proximal gut pushed into 
the lumen of the distal gut, so that the serous sur- 
faces are brought in contact. The apposition threads 
are then tied and a few Lembert sutures added. In 
this operation, too, scarification of the serous surfaces 
and use of omental grafts are of decided service. 
This operation is more difficult to perform upon a 
dog than upon the human subject, owing to the 
thickness of the muscular coats of the intestine of 
the former. In about one-half of my experiments 
with this operation the results were excellent ; but 
the results could not be compared with the results of 
the operations by lateral approximation, the mor- 
tality being too high. I would hesitate before 
performing the operation clinically and believe 
its field limited. Under some circumstances it 
would be impossible to do the operation satisfac- 
tory at all, where for example any considerable dif- 
ference existed in the diameter of the distal and prox- 
imal ends of the intestines. In experimenting, marked 
stenosis was found in several cases, which time might 
have relieved by a process of retrograde metamorpho- 
sis and atrophy of the invaginated gut. In all cases 
I found a ridge within the bowel at the seat of oper- 
ation. Lastly, if an ascending invagination be made, 
a fatal result will follow. Proximal accumulations 
within the bowel occurred in several of my operations, 
and death as a result of the obstruction and forma- 
tion of enteroliths occurred in several cases. The 
extreme distension of the proximal bowel was in some 
instances the cause of tearing of the sutures. The 7 
circular enterorrhaphy, theoretically, would be the 
ideal operation, and one congratulates himself upon 
the ease with which it may be performed by this 
method ; but at this writing I cannot but believe that 
the method of lateral approximation, taking every- 
thing into consideration, is much the safer operation. 
Matas, of New Orleans, (July number of the New 
Orleans Medical and Surgical Journal, 1889) has ex- 
perimented upon a cadaver with a catgut ring made 
of " Bass Violin String" (Drum snares) and particu- 
larly recommends their use in circular enterorrhaphy. 
The technique of the use of the Matas ring does not 
differ materially from that described above by me. 
Last December I made rings similar to those of 
Matas (eight months before the publication of his 
Fig. 5. Illustrating an Anastomosis after Enterectomy. 
article). The rings were subjected to the following 
test: a pair of them was placed in a glass of water 
and allowed to remain. Much to my regret, they 
became so twisted and contorted, that the idea of 8 
using them was at once given up ; aside from the 
loss of shape which they underwent, the gut ab- 
sorbed water to such an extent that they became 
twice their original diameter. The use of the seg- 
mented rubber rings in not limited to the intestinal 
tract ; there is undoubtedly a very wide field for 
their application and, with certain slight modifica- 
tions, the rings, as mentioned before, will be found 
of great aid in performing such operations as gastros- 
tomy, cholecystotomy, duodeno-cholecystotomy and 
jejuno-cholecystotomy. The first and last two men- 
tioned operations I have successfully performed upon 
dogs ; the second upon the cadaver. At a glance 
will be seen the advantages of the rings, in point of 
time particularly, likewise safety. My method of 
procedure in the above operation was about this : 
Gastrostomy.-In this operation a single ring is 
used. The stomach is drawn through a median 
incision, and an opening sufficiently large to admit 
a ring withan aperture of about one and a half inches 
is made. A ring provided with from six to eight 
apposition threads with needles attached should be 
used. Each needle is now passed through the walls 
of the stomach, traction is made upon the threads to 
see that the ring rests well in place, and the stomach 
is pushed back into the abdominal cavity. The 
needles are then passed through the abdominal walls 
and tied in pairs ; finally the margins of the opening 
in the stomach may be stitched to the skin, if thought 
desirable. This is briefly the technique of gastros- 
tomy. Feeding through such an opening may be 
commenced at once. This method of performing gastrostomy was 
devised by Dr. T. F. Prewitt, while using the Abbe 
ring in a series of experiments. In his first experi- 
ment the dog operated upon tore out the abdominal 
sutures some days after the operation and died from 
peritonitis. In a second operation the segmented 
rubber ring was used, and the dog made a perfect 
recovery, the result being all that could be desired. 
In my experimental gastrostomies the segmented 
rubber rings answered their purpose admirably and 
shortened materially the length of time in operat- 
ing. The operation may be done in fifteen minutes 
and even less time. 
Cholecystotomy.-In performing this operation, 
the gall bladder is aspirated after opening the abdo- 
men, or a more rapid way of dealing with the contents 
would be to incise and allow the contents of the 
gall bladder to flow into the ingenious spoon devised 
by Keen and Musser. The neighborhood of the 
gall bladder should be thoroughly packed with flat 
sponges, to protect the parts from any accidental 
leakage. The opening in the gall bladder may now 
be enlarged sufficiently to admit the introduction of a 
small segmented rubber ring. I have used one about 
the size of a quarter in such experiments. From six 
to eight apposition threads are attached to the ring; 
these are threaded and passed through the walls of the 
gall bladder from within outwards, then through the 
parieties, and tied in pairs. The skin and margins of 
the gall bladder may be united by a few extra sutures. 
After firm union has taken place, the ring in whole 
or in part may be drawn out through the fistulous 
track, with forceps. 
9 10 
The use of a rubber ring in this operation will, I 
believe, reduce the risk of extravasation after the 
operation to the minimum, besides saving much time. 
The ideal in certain cases would be to establish a 
direct union of the gall bladder and some portion of 
the intestinal tract ; this may be accomplished in 
two ways. The first by using two segmented rubber 
rings, the second by a single ring. In the first case 
a ring is introduced into the gall bladder, with the 
precautions mentioned in the preceding operation, 
and a second is placed in the intestine, either the 
duodum or jejunum. The parts are now placed vis- 
a-vis, and the apposition threads tied; a few extra Lem- 
bert sutures are added and the operation is complete. 
In one of my experiments I placed a small piece of 
rubber tubing, one-sixteenth of an inch in diameter 
and two and a half inches long, into the opening 
between the gall bladder and the intestine, two-thirds 
of this tubing extending into the intestine and one- 
third into the gall bladder. This was done with the 
idea of aiding the immediate drainage from the gall 
bladder into the intestine. Whether it served any 
good purpose or not, I am unable to say ; but the 
dog is at present perfectly well. With a free opening 
in the gall bladder, it will be but a question of time 
when the rings or segments will find their way into 
the intestinal tract. With a single ring I proceed 
thus : The loop of intestine (duodenum or jejunum) 
is clamped, and after the abdomen has been packed 
with flat sponges, around the seat of operation, an 
incision one-half inch in length is made in the 
intestine. A ring is used with the apposition threads 11 
looped, and in each loop is threaded a needle. The 
gall bladder is emptied and an opening made of the 
proper size, about half an inch or three-fourths 
inch in length; the ring is introduced into the 
intestine and the threaded loops passed through the 
intestinal walls. The needle-threaded loops are now 
passed through the walls of the gall bladder, half an 
inch from the margin of the wound. Then the loops 
are cut and the needles removed, withdrawing one-half 
of the loop, after passing it through the walls of the 
gall bladder. The threads are tied in pairs, or what 
would be better, after passing the looped apposition 
threads through the intestinal wall, the loop might 
be cut and only half carried through the wall of the 
gall bladder, and the halves then tied. A few extra 
Lembert sutures added gives additional security. 
Fig. 6. Gunshot Wound 
The technique of duodeno and jejuno cholecysto- 
tomy are so similar that one description will apply 
to both. Aside from the operations mentioned, these 
rings may be used with advantage in attaching ab- 
dominal cyst walls to the parieties, when by reason 
of attachments, adhesions, or relationships to various 12 
organs, removal is contraindicated ; e. g., ecchinocotic 
cyst, etc. ; and the same treatment might also apply to 
certain abscesses or pathological fluid accumulations 
in a viscus or a part of a viscus, where free external 
drainage is indicated, by making a secure attachment 
to the parieties. In the Weekly Medical Review of 
Aug. 17, 1889, in an article by me on this subject, is 
mentioned a new procedure for rapidly closing large 
wounds of the intestines, especially gunshot wounds, 
where by ordinary suturing a stenosis would result. 
My experimental work with this operation has been 
highly successful. This method of treatment applies 
particularly to wounds of the surface of the intestine ; 
wounds of the mesenteric portion would usually re- 
quire resection. It was suggested by me if the 
wounds were wide apart to close each with a single 
segmented ring in this manner : after trimming and 
enlarging the wound with scissors, an oval ring made 
of eight segments of tubing, with an aperture of two 
and one-half inches, is placed in the bowel. Six ap- 
Fig. 7. Eight Segment Ring. position threads should be used with this ring, one at 
each end and two on each side, so arranged, that 
when tied, the ring is held bent upon itself. The 
ring is introduced into the bowel, the end apposition 
thread passed, then the lateral : the ring is doubled 
upon itself, and the end threads tied first, next the 
lateral apposition threads. To prevent eversion of 
the margins of the wound, particularly at the point 
of flexure, a single provisional catgut suture is used 
in drawing the margins of the wound in the bowel 
together. In most cases it is only necessary to draw 
upon these margins, until they come within a quarter 
of an inch of each other, when it is tied. 
13 
Fig. 8. Ring bent upon itself. 
This simple procedure will effectually prevent 
eversion of the wound margins. The suture is dis- 
solved or digested in a very short time. After tying 
the apposition threads, a few Lembert sutures are all 
that is necessary to complete the operation. By this 
means an opening in the bowel the size of a half a 
dollar may be closed in less than five minutes. When two wounds of the free surface of the intes- 
tines are close together, and especially if in the same 
loop, I would suggest, if possible, to form an anas- 
tomosis by lateral approximation. This does not 
apply to wounds by bullets of small calibre, but when 
the wounds are quite large. When more than two 
wounds are very close together, excision of the 
damaged gut and formation of anastomosis will re- 
quire far less time than a classical circular enterorr- 
haphy, or even the mere sewing up of several wounds. 
Aside from gunshot wounds, there are other con- 
ditions where the single ring might be used with ad- 
vantage, probably saving a resection in some cases : 
for example, perforating ulcers in any part of the 
14 
Fig. 9. Ring in the Intestine before tying. 
gastro-intestinal tract, cases of stenosis when the 
stricture can be cut through thoroughly, as in the 
case of a stricture following a hernia, closure of the 
opening made after removal of an impacted foreign 
body, such as enteroliths when there are structural 15 
changes in the intestinal wall, etc. The resulting 
aperture of the intestine when the single ring has 
been used, will be found to be all that could be de- 
sired, as my specimens and photographs of the same will 
show. The great advantage of the segmented rubber 
rings over the devices recommended by writers upon 
this subject, is the simplicity of their construction. 
They may be made in case of emergency in a very 
few moments. One called upon suddenly to operate 
upon a gangrenous strangulated hernia has no time 
to lose, and with a pocket case and a piece of tubing, 
or even a soft rubber catheter, I should feel well 
satisfied that the indications for a resection could be 
met, and above all, the operation completed in a few 
minutes. Experience has shown that minutes are 
hours at times in such cases. 
Before giving the tabulated results of my experi- 
ments I will state, that the dogs experimented upon 
were kept together in one room with a very few ex- 
ceptions, both before and after being operated upon. 
Fig. 10. Ring bent double and sutured in position. 16 
They were fed upon raw meat and bread ; the more 
vicious animals were tied in the same room. The 
number confined varied from six to twenty-eight, and 
as might be expected, fights were frequent. I feel sure 
had circumstances permitted the keeping the dogs 
separate after the operations, the good results ob- 
tained would have been far better. From time to time a 
dog was isolated, so that the date of the passage of the 
rings or segments might be noted : but for the most part 
I have had to depend upon the post mortem to find 
with certainty whether the rings had passed or not. 
With but one or two exceptions, no trace of the rings 
could be found after seven or eight days ; rings and 
segments of rings were frequently passed as early as 
the fifth day. Post mortems were seldom held be- 
fore the ninth day and usually only after a few 
weeks. 
The large aperture of segmented rings makes it 
possible to perform the operation of ileo-colostomy by 
the following method, which I believe is original. 
The ileum being divided a short distance from its 
junction with the caecum, the divided end of the 
distal bowel is invaginated into itself and secured by 
a continuous suture, through the serous and muscular 
coats only. Above the proximal end of the gut a 
clamp is placed, and a segmented ringadjusted to the 
lumen of the bowel in the same manner as for a cir- 
cular enterorrhaphy, and a slit of sufficient length is 
made in the convex surface of the ascending colon. A 
ring is then introduced into the colon, in the same 
manner as for a lateral anastomosis. After checking 
all bleeding, the proximal end of the divided small 17 
intestine is inserted into the slit, and all apposition 
threads tied, adding Lembert sutures. This opera- 
tion may be very quickly performed, and is indicated 
in such cases as irreducible intussusception of the 
ileum into the caecum and malignant diseases of the 
colon. 
Appended is a series of operations with the results. 
Gastrostomy, two experiments ; two recoveries. Gas- 
trojejunostomy, three cases, two recoveries, one 
death from peritonitis ( dog tore out sutures eight 
days after operation). One jejuno-ileostomy, result 
perfect. Ileo-ileostomy, two cases, one death, due to 
perforations and peritonitis. Ileo-colostomy, two 
cases, two perfect results. Colo-colostomy, three 
cases, one death. Ileo-rectostomy, two cases perfect 
results. Circular - enterorrhaphy, 14 cases, seven 
deaths. Duodeno-cholecystotomy, three cases, two 
deaths from peritonitis. This operations is very 
difficult to perform on the dog for anatomical reasons. 
Single ring :-Partial Duodenectomy, two cases, 
one perfect result. Partial Jejunectomy, two cases, 
two perfect results. Partial Ileectomy, four cases, 
one death. Partial Colectomy, two cases, two perfect 
results. 
Summary :-Intestinal Anastomotic operations, 
fourteen cases, three deaths. Circular enterorr- 
haphy, fourteen cases, seven deaths. 
The single ring formed of eight segments of tubing 
was used in closing wounds varying in size from a 
quarter to a half dollar in nine cases with one death. 
The clamp devised by me and used in these 
operations, is made of No. 13 copper wire covered 18 
with unperforated rubber tubing of small size. The 
extremities of tubing overlapping the ends of the 
wire are ligated, and the rubber covered wire is bent 
upon itself. The clamp is applied by slipping it over 
Fig. 11. Clamp of No. 12 Copper Wire covered with rubber tubing. 
the free margin of the intestine, at the same time 
pushing 'the lower blade through the mesentery, 
fairly close to its junction with the intestine. The 
blades are made perfectly parallel and an elastic band 
or heavy ligature is thrown around the ends of the 
clamp. This clamp will be found to answer its 
purpose perfectly. 
"Note." On the 18th of Sept., 1889, I had the 
pleasure of assisting my friend Dr. N. B. Carson of 
St. Louis, in performing a gastro-jejunostomy in a 
case of carcinoma of the pyloric end of the stomach ; 
in this operation two segmented rubber rings were 
used, the patient recovering from the operation 
without a bad symptom.