If there is time to prepare the patient it is desirable that the condition of the mouth should be attended to, and that aseptic foods should be given for forty-eight hours before operation. To this end I am accustomed to recommend patients to wash their teeth with a 1 per cent, solution of carbolic acid several times daily for two days before operation. I also direct that nothing but food that can be sterilised by boiling or cooking should be given, and that the plates on which it is served, and the utensils used, should all be sterilised by boiling water before use.
Except in cases of marked retention of the stomach contents I am not accustomed to have the stomach washed out before operation, unless the patient has been accustomed to it, and can submit to it without inconvenience; but if there is retention of the stomach contents, as in many cases of pyloric stenosis, I sometimes have the stomach washed out night and morning the day before operation. No food is given on the morning of operation, but a pint of saline fluid, with 1 oz. of liquid peptonoids and 1 oz. of brandy, is given by rectum about half-an-hour before. I usually order a dose of castor oil to be given two nights before, to be followed by an enema the night before the operation is arranged, thus avoiding the necessity of disturbing the patient later. As it is important that the patient should be depressed as little as possible by cold, I have him enveloped in a loose gamgee tissue suit, which can be readily run together by the nurse in an hour or two. The skin of the abdomen and lower thorax is thoroughly washed with soap and water the day before operation, and a 1 in 1000 solution of biniodide of mercury in 70 per cent, alcohol is applied on lint, which is then covered with jaconet or oiled silk and fixed by a bandage, the dressing being changed and reapplied on the morning of operation.
The stomach is exposed by a vertical incision made an inch to the right of the mid-line from a point a little below the ensiform cartilage downwards to the level of the umbilicus. The anterior rectus sheath is incised to the same extent, and then the rectus is either retracted externally or the muscle is split, after which the posterior rectus sheath and peritoneum are divided to the same extent. I prefer this incision to the one in the mid-line, as the latter forms a less secure scar, and is inconvenient in case the incision has to be prolonged; moreover, the round ligament, with its irregular adipose envelope, is apt to be in the way.
Should operative measures demand an extension of the incision, it can be prolonged as far as necessary without weakening the abdominal wall, as no muscle is divided in the process. The stomach is now exposed and the whole of the anterior surface can be seen by retracting the margins of the incision and raising the lower border of the liver. If the posterior wall of the stomach has to be examined, the great omentum and the transverse colon should be brought out of the wound, and a vertical incision is then made through the transverse meso-colon, through which the fingers can be passed so as to explore the whole of the posterior gastric wall.
This will end the exploratory abdominal section qua exploration, but if needful any further operation can then be proceeded with.
Should nothing further be required, the abdomen is closed by a continuous suture of No. 3 iodised catgut, the peritoneum and posterior aponeurosis being first united, the suture returning along the anterior aponeurosis till it reaches the point where the stitching was begun, after which the two ends of catgut are tied and cut short. In order to strengthen the line of sutures two or three interrupted sutures of No. 2 lightly chromicised catgut are passed through and through the aponeurosis and muscle and drawn just tight enough to approximate all the layers, but not so tight as to endanger the tissues being strangulated, after which the edges of the incision are brought together by Michel's metal sutures. Aseptic, dry, double cyanide gauze is then applied, and over this aseptic wool, strapping, and a many-tailed bandage, care being exercised not to compress the lower thorax unnecessarily.
When performed for cancer, the incision need not be larger than to admit two fingers, as it is easy to extend it should that be necessary for more thorough exposure of the stomach. It may be performed under local anaesthesia if thought necessary, but as a rule a general anaesthetic is desirable.
If no disease of the stomach be found, the small incision can be securely closed, and the patient may safely be allowed on the sofa within the week.
If the disease is found too extensive for removal and no further operation be required, it is most desirable that the few remaining weeks of life should not be spent in bed, and if the aponeurosis and muscles are united by buried through-and-through silver sutures or by silkworm-gut sutures, and the wound covered with a collodion dressing, the patient may safely be allowed on the couch on the second or third day. The risks of an exploratory operation for diagnostic purposes in an early stage of disease are practically nil, and in efficient hands are only likely to occur from some accidental cause, such as pneumonia or pulmonary embolism.
In the later stages, when there is tumour and the disease is too advanced for removal, the risk is, of course, greater, and depends on the condition of the patient rather than on the operation.
Kronlein had a mortality of 9'5 per cent, in seventy-three cases, four from exhaustion, two from pneumonia, and one from pulmonary embolism.
Von Mikulicz had four deaths in forty-four cases -9 per cent., and the duration of life after operation averaged four months.
As these statistics include cases operated on several years back, needless to say they show a much higher rate of mortality than would a corresponding number of cases operated on to-day. Arguing from my own cases the mortality should, I think, not exceed from 2 to 3 per cent. In the St. Mary's Hospital (Rochester, U.S.A.) report for 1905, the brothers Mayo record twenty-five exploratory ojDera-tions for carcinoma without a death, and in a later communication they report having explored the abdomen in seventy-two patients where the disease proved to be beyond removal, with one death. The average stay of these cases in hospital was less than five days.