Zielewicz (Centralblatt f. Chirurgie, No. 13, 1888,) proposes in
addition to the so-called “ideal” method of Spencer Wells, that of
suturing the gall bladder to the abdominal wound, to ligate the cystic
duct, in order to insure the patient against the return of the biliary
lithiasis. The only case in which he has tried it was one in which an
attempt was being made to perform cholecystectomy, but the adhesions
between the gall bladder and liver were so dense and unyielding as to
render the removal impossible, on account of severe hæmorrhage. He
therefore passed two ligatures around the cystic duct and divided the
latter between them. The gall bladder was then fastened to the abdominal
wound, incised and emptied of its contained calculus and biliary
secretion. The patient made a good recovery, a fistula remaining, of
which the writer says, that “after a time it was almost closed.”
The author claims for this operation the following advantages: 1st.
Rapid healing without a resulting fistula. The gall bladder is
practically removed from the organism. With appropriate after treatment,
its secretion soon ceases, and it becomes obliterated. 2d. The operation
is simple and less dangerous than cholecystectomy, and gives the same
results.
In contrasting this operation with cholecystotomy, it may be said that
the latter simply aims at removing the existing calculi, and makes no
provision against the recurrence of the same. Where the “natural” method
of Bernay is adopted, and the gall bladder dropped back into the
abdominal cavity after suturing the incision made in its walls for the
removal of its contents, in case of a recurrence of the disease, the
entire operation must be repeated. In the “ideal” method of Spencer
Wells, only an incision need be made, in such an emergency, at the site
of the first operation. Troublesome fistulæ, however, are apt to remain.
In cholecystectomy, on the other hand, hæmorrhage from breaking down of
adhesions between the gall bladder and the surface of the liver, it is
claimed, is a frequent and troublesome complication. It is claimed by
Thiriar, however (“De l’intervention chirurgicale dans certains cas de
lithiase biliaire,” _Revue de chirurgie, 1886, No. 3_), that
cholecystectomy is a less dangerous operation than simple
cholecystotomy. Again, by Bardenheuer, that hæmorrhage from the liver
can be readily arrested. The abstractor witnessed an operation in which
the liver was accidentally wounded and the resulting hæmorrhage arrested
by the thermo-cautery.
Hertin, a French naval surgeon, in 1767, after experiments made upon
dogs, proposed, in wounds of the gall bladder, extirpation of the
latter, after ligature of the cystic duct. In these experiments he
demonstrated the feasibility of the operation of cholecystectomy upon
the lower animals, at least.
Campaignac, in 1826, proposed ligature of the cystic duct, with partial
resection of the gall bladder (Journ. hebdom. Bd. ii, 1829). K. Zagorski
has recently attempted this latter procedure on dogs, with fatal results
(Przegl. lekarski, 1887, No. 48). Nevertheless, to Zielewicz belongs the
credit of being the first to demonstrate, by its successful performance,
the feasibility of combining in man the two operations of ligature of
the cystic duct and cholecystotomy with suture of the gall bladder to
the abdominal wound. Upon further trial the operation may prove to be
not only feasible, but to follow out a rational indication with relative
safety.