CASE OF VENO-VENOSTOMY FOR THE RELIEFOF ASCITES.

By SIR CH1\..RLES BALL, BART, lVI.Ch., F.R.C.S.;Regius Professor of Surgery, Univ. Dubl. ;

Surgeon, Sir Patrick Dun's Hospital and President, Royal Academy ofMed icine in Irelana.

[Read in the Section of ~urgery, December 8, 1911.J

CASE.-T. D., an alcoholic woman, aged thirty-five, ap­plied to the Rotunda Hospital, as she believed herself to bepregnant. It was then found that this was not the case,but that she had ascites. She was tapped and transferredto Sir Patrick Dun's Hospital on November 10th, -1910.

Fourteen days after the first tapping the peritonealcavity was again tightly distended with fluid. Her abdomenwas opened, and the fluid withdrawn. The liver was foundto be considerably enlarged, and the surface felt rough andgranular. She was washed out with normal saline solution,and the peritoneum subsequently completely emptied.

The fluid in her abdomen rapidly accumulated again. OnNovember 30th she was treated by lymph-angioplasty. Herabdomen was opened on the right side, an incision madeover the saphenic opening, and a probe passed through thefemoral canal until the peritoneum was felt protruding overthe point. Through a small incision in this protrusion theprobe passed into the abdominal cavity. By its means twoloops of thick floss silk were brought through the femoralcanal into the abdomen, and sutured with fine silk to theparietal peritoneum. The four ends of these two loops pro­jectingfrom the saphenic opening, were then distributedby a long probe to different parts of the subcutaneous tissueof the thigh, one extending nearly down to the knee. Thisoperation was quite unsuccessful in preventing the accu­mulation of ascitic fluid. In three weeks she was againfully distended.

144 Veno-oenoiomu for the Relief of Ascites.

On December 21st the following operation was under­taken :-An incision was made from the left saphenic open­ing down the thigh over' the course of the vein for aboutten inches. The vessel was ligatured and cut across below,and dissected out up to bhe point at' which it went in deeplyto join the femoral vein. The abdomen was opened by anoblique incision over Poupart's ligament, and the loweredge of the peritoneal incision separated from the pelvisuntil the femoral ring was exposed. A sinus forceps wasthen pased through the femoral canal out at the saphenicopening, and by separating the blades the canal wasdilated. With this forceps the cut end of the saphenicvein was brought through the canal into the pelvic sub­peritoneal tissue, care being taken not to strain it suffi­ciently to form a kink where the vein passed down to jointhe femoral. The pelvic meso-colon was then examined,and unfortunately it was found to be thickened by old­standing peritonitis, the left ovary being adherent to it, sothat no veins could at first be seen in the meso-colon. Anincision was made through the outer layer of peritoneumof bhe meso-colon, and by means of blunt dissection a largesigmoid vein was soon found. By separating the peri­toneum with the finger from the incision in the meso­colon, the primary wound in the abdominal wall was easilyreached, so that the saphena vein could be brought up intothe meso-colon altogether extra-peritoneally. The sigmoidvein was isolated for about an inch, clamped at the intes­tinal end, ligatured and divided at the other extremity. Theopen end of the saphenal vein was now turned back, as oneturns up the end of one's trousers in wet weather, and theopen end of the sigmoid vein sutured with very fine ophthal­mic needles and silk to the turned edge of the opening in thesaphena vein. When this was completed, the turned upend was replaced, so that the end of the intestinal vein wasfixed to the inside of the larger vein about one-quarter ofan inch from its cut extremity. The .clamp was removedfrom the sigmoid vein and blood' could be seen to flow from.it into the saphena vein without leakage at the line ofunion. The wounded peritoneum of the meso-colon wassutured.

By SIR CHARLES BALL, Bart. 14D

Before closing the abdomen the site of the silk drains onthe opposite side was felt, and it was found that they hadbeen smoothly covered by lymph, so that they were uselessfor draining the peritoneum.

The patient made a rapid recovery, but a moderateamount of fluid reformed in 'the peritoneum, so she wastapped again on January 18th, after which she remainedwell. She went home on February 1st, and several timesduring the past summer came to the hospital to show her­self, with no ascites and very much improved in health.

About two months ago she began again to drink heavilyand ascites carne on, so I had to admit her into hospital,and on Tuesday last tapped her and drew off a moderateaccumulation of fluid. It is only reasonable to supposethat if she had given herself fair play she would have re­mained longer well.

The case is one of interest, as it again demonstrates thefutility of attempting to establish a permanent drain fromthe peritoneum into areolar tissue by means of silk. It isalso of importance as showing that it is not difficult toestablish a connection between the saphena and one ofthe large tributaries of the mesenteric veins, thus forminga siphon between the portal and caval circulation capableof relieving the blood in the 'portal vein from undue ten-.

sion.

Mn. W. I. DE C. WHEELER said that what Talma andMorrison had. attempted in a rather clumsy manner had beensuccessfully accomplished by Sir Charles Ball. He hadfound the Talma operation to work well in a case of ascites,but he would not advise it to be attempted except in properlyselected cases.· No patient suffering from jaundice, cirrhosisof the kidney ,01" heart affection could be considered suitablefor such an operation. Patients suffering from atrophicascites he considered most favourable ones for the operation.

]VIR. GUNN said he had once attempted to anastomose the

'f. K

146 VC1't0-Vertot0'111Y for th.e l~elief of 11 sciies.

ovarian and portal veins, but failed. The failure he attri­buted to the patient's age, and also, perhaps, to the ovarianvein being so small. It seemed to him that in theseMorrison cases the patient either improves immediately 01'

there is no improvement at all. If the improvement was dueto the anastomosis being satisfactory, one would expect it tobe of a gradual nature. He would prefer to try the operationsuggested by Sir Charles Ball than the Morrison.

l\IR. STONEY said that although he considered the operationdescribed by Sir Charles Ball a most excellent one, he didnot think that lymphangioplasty could be dismissed by sayingit was always an absolute failure. He had experience ofthis operation in a case of polyserositis, and found it mostsatisfactory.

SIR CHARLES BALL, in replying, said he was glad to hear ofMr. Stoney's case of lymphangioplasty as his own results hadbeen Blast disappointing.