RADICAL OPERATION FOR VENTRAL HERNIA 371 



the Contents and Exposing the Outlines of the Orifice.— 



When the sac has been opened wide from end to end of the 

 incision its inner wall is examined for adhesions of the omen- 

 tum, which if found to exist are broken down, ligated with 

 gut and cut off, while the stump is returned into the abdomen. 

 The omental vessels always bleed copiously if not ligated, 

 and instead of searching about for the vessels themselves, a 

 tedious, impossible matter, the whole exposed part is ligated 

 en masse. The next step is to expose the boundary of the 

 orifice so that at least one' inch of space around its edge is 

 available for suturing. 



Third Step.— Closing the Orifice.— This step begins by 

 bringing the edges together as closely as the tensile strength 

 of the gut admits, with as many through-and-through mat- 

 tress sutures as are required. Contrary to expectations, the 

 approximation of the edges will be found quite easy ; no great 

 amount of stretching will be required. After the mattress 

 sutures the edges are brought into perfect apposition with in- 

 terrupted sutures placed close together and in such a manner 

 as to place peritoneum to peritoneum, the only tissue from 

 which prompt union may be expected. The cicatricial tissue 

 of which the boundary is composed will not unite, even if 

 scarified. . 



Fourth Step. — Closing the Sac. — There will be some, al- 

 though not much, redundant skin in the sac, to resect in order 

 to make the flaps fit against the wall. But the mistake of 

 resecting too much must not be made. The danger in this 

 connection is overcome by first placing a row of mattress 

 sutures along the level of the body and then cutting off the 

 skin about an inch above them if that much exists. After the 

 skin is thus resected a row of interrupted sutures is placed 

 along the edge, except at one point which is left open for 

 drainage. 



Fifth Step. — Dressing. — A pad of cotton held against the 

 wound with a number of tight wraps of strong muslin around 

 the body to act in the double capacity of supporting the su- 

 tures as well as to immobilize the respiratory movements, is 

 the required dressing. 



AFTER-CARE.— On the third day the bandage is perfor- 

 ated at the level of the drainage orifice to facilitate evacua- 

 tion of accumulated secretions. The temperature is taken in 

 the expectation of septic complications, and if no fever de- 

 velops the wound is not molested until the eighth day, when 

 removal of the bandage and the skin sutures may be thought 



