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·OPERATIVE PROCEDURE

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·Ο Ρ Ε R Α Τ Ι V E
P RO C E D U R E
This book was first published in the
United States of America, where it has
proved of great service to surgeons and
medical students alike
The few copies which reached this
country were so warmly welcomed that
the publishers decided to print a British
edition of the book
Text and illustrations remain identical
with those in the original American
edition
Johnson-Johnson
(GREAT BRITAIN)
Slough
Bucks
England

·COPYRIGHT IN USA
1939
JOHNSON & JOHNSON
Printed and made in England at the Fanfare Press London

·میه K Jone The Origin and Function of the 'Operative Procedure' Series This series of plates published by Johnson & Johnson in the leading surgical journals of the United Stales of America was prepared in collaboration with the staff of Surgery Gynecology and Obstetrics THE SURGEON who casually views or carefully studies these illustrations will realize that they are not to be found elsewhere in medical or surgical literature As originals, it is understood that they have to be carefully prepared but the amount of effort expended in selecting the subject and then tater selecting the important steps to be illustrated may not be comprehended as quickly ·There is probably no branch of science or art which has given more evidence of progress in the last two decades than the science of surgical technique The perfection of older methods and originality in new methods have given to the world a mass of material which is worthy of careful immediate study and preservation for future reference The selection of the subjects in this series was made with the help of several surgeons whose practice and experience enabled the pointing out of not only the most timely technique but likewise the outstanding steps In this way the artist was furnished with material from which he might accurately illustrate approved technique in a new and original manner LIGATURE DEPARTMENT JOHNSON & JOHNSON SLOUGH BUCKS

·SUTURE TECHNIQUE (NO 1)
CONTINUOUS
PURSE STRING
Tied
Two types
INTERRUPTED
"Interrupted
LEMBERT
CUSHING
All needles
in position
Continuous
MATTRESS
SUBCUTICULAR
Perforated
shot
Closure
Jones
Intérrupted
Continuous

·SUTURE TECHNIQUE (NO 2)
To yones
+ section
Gauze
BLANKET
Tying over gauze
Od
DOUBLE BUTTON
Ligating pedicles
FIGURE OF EIGHT
(made around pins)
THE
SQUARE
OR TRUE
KNOT
HALSTEAD
Reinforced
2

·SUTURE TECHNIQUE (NO 3)
METHODS FOR SECURING THE ENDS OF CONTINUOUS SUTURES
Double
Single
Cut
Single
Subcuticular
wBeginning
Free
Strand
(REDER)
End
777
chtbilleder
Beginning
knot
071117'
TRANSFIXING LIGATURES
TO PREVENT SLIPPING
Shepsi
Pedicle
B
Omentum
or hermal sac
C
Vessel
3

·SUTURE TECHNIQUE (NO 4)
"NO HAND-TOUCH TIE (Murphy)
Assist.
8
First half-hitch
Right
Right
Assistant
A/Left
A
Lert:
Surgeon
D
E
Assist
Left
Right
F
Second half hitch
Left
Shepard
4

·CLOSURE OF SKIN DEFECTS
e
2
2
2
3
of MTI
6
Show

·SUTURE TECHNIQUE (NO 4)
"NO-HAND-TOUCH TIE (Murphy)
Assist
First half hiteh
C
Right
Right
Assistant
(Left
Left
Right
Surgeon
D
E
Assist
Left
Right
F
Ruant.
Second ha
eft
half pitch
Shepand
4

·CLOSURE or SKIN DETECTS
a
a
b
Shepard
Y Tom Jones
Thoduperen

·RESECTION FOR EPITHELIOMA OF LIP
Fonts
EARLY CASE
с
Sutures tied (Note ful
ness in center to prevent
subsequent notching)
مالی و مالی
A
Ir cision
Sutures in position
(Stitches in inucous
membrone tred first)
MORE ADVANCED CASE
3
BV
Inclions AA Triangles of skin
removed to permit reconstruc
tion of lower lip BB Incision
for removal of lymph nodes
B
Operation completed Note
réconstructed' vermilion
border CC of mucous
membrane of cheek
6

·OPERATIONS FOR HLARCLIP-SINGLE CLETT INCOMPLETE Simplc noch When nostril flattened, fissure made complete for better repair Area excisco (Gracfc) ܝܝ ni Men Suture Anca excised (Rose), Kepal COMPLETE Lip and cheek undermined Edges of premaxilla and alveolar proc refreshed pushed into line and wired с Areas excised (Rose) Transfixing incisions to refresh edges "bu)! E {ftPL Figure-of-8 stitch www. Traction Flaps to be trimmed allowing för scar contraction

·SKIN GRAFTING INLAY GRAFTS
Incision
B
Raw surface resulting from
simple dwon of scorand freeing of tension
А
Profile
Burn contrecture of neck
dental stent,
face
Graft
new after result
End
rest
Gratt with raw surface out
ward wrapped about mold of dental stent
Graft covered mold
buried in raw surface
8

·SKIN GRAFTING FOR BURN CONTRACTURE
After excision of
scar tissue
Burn contrac
ture of hand
Heard place in peskiet flap
onánt surface of thigh
Peducing size of
defect by draw
ingin
edges
ให้
C
Lire: nong, which
flap is dinded
D
Cervenangrow surate with
Thiersch graft (one week later)
9

·TREATMENT OF BURN CONTRACTURE OF AXILLA Burn contracture of axılla Hiline Posterior view Suture of flop on arin Separation of 2 layers of web preparatory to Z shaped plastic Broad web of healthy tissue Alternate method Thierschs Qrafts Raw sur face at apex of axilla covered by full thickness graft Suture of flaps completed Use of pedicled flap to cover apex of axılla 10 ·SKIN GRAITING TRUL IULI TUICHNLSS GRAITS Bum Artist urs of hand Cutting can fosil pottern of row 'Surfoce A extent of new surface resulting from excision of scar Cutting Craft on inside of thigh from pattern Bondage Sea sponge Xeroform foure Plain Gaute- Section, Gisft Aluminum spint section C Long Suture of Proft completed with fine sutures Application of pressure dressing over graft man ·TREATMENT OF BURN CONTRACTURE OF AXILLA Burn contractura of axalla Postemor view Broad web of healthy tissue Separation of 2 layers of web preparatory to Z shaped plastic Suture of Flap on arm Altemate method Thiersch grafts Raw sur face at apex Suture of flaps completed of axilla covered by full thickness graft Use of pedicled flap to cover apex of axilla IO

·SKIN GRAFTING-SPLIT GRAFTS
Ordined with
scalpel
Excision of granulation
ti sue frorn raw area
Cutting of graft
Skin under tension
Holes for escape of
blood & serum
Şea sponge
Dry gauze
Vaseline
dauze
Graft
Adhesive
Pressure dresing
in croe section
Anchonng graft
with fine skin suture
Teasing Sraft into
position with needles
13

·FULL THICKNESS GRAFT WITH SLIDING FLAP TJone Groft to cover raw surface onleg Superficial scar adherent to bone Incision Defect resulting from Osteomyelitus Denuded surface of ubia ready for sliding flap Frontal Section A B Bandage--- Seo sponge- Graft Free full thickness graft Plain gauze Xeroform Sauze- Bandage Groft + Section Flap shifted to cover exposed tibia Resulting row surface covered by graft 12 ·SKIN GRAFTING-SIEVE GRAFT (NO 1) DOUGLAS Donor skin incised following pallem-44 larger than area to be covered Islands bored thru donor skin with steel die SHT under tension Dies BA + section Knife edge reversed to complete) Transplant sutured over recipient Site Islands ieft on donor site Island lepressed Skin undercut with knife inserted thru die incisionsperiphery raised last Choperty 15

·DELAYED PEDICLED FLAP
Flap raived and
Sutured back in its bed
Scar tissue excised
over patella
Previously raised flapon me
dual surface of other leg healed
end ready to be transferred
Burn contracture over anterior sur
fose of knee preventing flexion
Flap şutured in position
Thierset fraft from
back of thigh
Jarly
Result after division of flap and
Suture of remaining raw surface
Raw surface left by elevation
of fiap immediately covered
by Thuersch graft
4

·IDEAL TREATMENT OF LACERATED WOUND
Cleansing of wide arco
around wound
Sterile pad
protecting wound
Recent Coated
wound Righ
Relaxation incision
to permit apposition
of skın edges
+ section
Complete excision of
contaminated tissue
Wound
now clean
Approximation
of deep tissues
Raw surface immediately
covered by Thiersch graft
Toe Jones
17

·SKIN GRAFTING-SIEVE GRAFT (NO 2)
DRAGSTEDT-WILSON
Joval shaped
full-thickness
transplant taken
from abdomen
Transplant
placed on towel
moistened with
salt solution
Comparison
on recipient
and donor
Grill
Multiple
overlapping
incisions
Axis of unstretched
Fraft
Sieve graft sutured
to recipient site
Skin defect closed
over donor site
D
Graft
can be stretched to
fit varied shapes
Thepard
16

·TECHNIQUE OF NERVE SUTURE k C Guy, sutures in Cheath on postemor aspect of nerve to relieve ten sion on nerve ends B Successive slices made with shar? knife until nor inal funiculs are seen A Dindad nerve ends imbedded in SCA tissue Suture completed irst şuture applied at exact midpoint of Posterior and anterior surfaces + section D F Rotation of nerve as each succeeding suture is inserted H Fiap of Fat to protect nerve at line of suture To com 19

·IMMEDIATE TREATMENT OF CRUSHING
INJURY OF FOOT
After excision
of crushed skin
Thiersch groft
immediately applied
to raw surface
Exposure of
deep structures
on dorsum of foot
a3 result of
injury
Preparation of
pedided flap from
opposite leg
Healed flop detached and
suature of both wounds completed
Suture of flap over
raw surface
Heales
Thiersch
Graft
TO JONES
18

·Phrenica
PHRENIC NEURECTOMY
Incision
Sternomastord
muscle
Omohyoid or
Phrenic nerve
Exposure
Level of diaphragm before and after operation
Evulsion of
nerve by
rotation of
forceps
Closure
Nerve divided above
grasp of forceps
21

·NERVE SUTURE Median mexve- Flexor tendons Medion Derve Neuromat suk B A Common site of injury to median Dervé Typical appearanor of field of operation following injury to nerve and tendons Technique of nerve repar 1int nerve Fat transplants Operation com pleted Hard main ained in seru flered position toinsure Ineedom from tension on sutured nerve ends E Jones - D Fat transplant to protect sutured nerve from odhesions 20

·PIIRENIC NEURECTOMY
Incision
Phrenicnt
Stertomastord
muscle
Omohyoid m.
Phrenic nerve
Exposure
Lecer of diaphragnl before and after operation
21
Evulsion of
nerve by
rotation of
forceps
Closure
Nerve divided above
grasp of forceps
To Jones
21

·NERVE SUTURE Median nerve- Flexor tendons Neuroma Median nerve Finest black A ܬܐܕܦ B Common site of injury to median nérvé بأننا سنلعبدلالانكلتلحلحلته Typical appearance of field of operation following injury to nerve and tendons с Technique of nerve repair Fat transplant Plant $ an nerve Medic Operation.com pleted Hard main tained in seru flesed position to insure freedom from terasion on sutured nerve ends E Jones D Fat transplant to protect Sutured nerve from adhesions 20

·TENDON LENGTIENING AND SIORTINING
IDOL LENOVO
Accord on br
Ponces mitnod
4:32ction, ttino
end (1473
Os querection
ond guiding
Interposed silki
suture's (Lange
method)
TE DO SOROVING
Hoffas
trethod
Incision
Erds exased
Remo al of sertion and
mortise ubion of ends
Doubling
23

·TENDON SUTURES
B
Finished result
Two methods of inserting,
stay Sutures in divded tendons
Rotation of tendon
to permit insertion of sutures
for accurate coaptotion
Sechonal
Graft
View
of
of insertion of
sublinis
Graft of
flexor dig sublinis
Tones
D
A common site (x) of tandon
igjury, with resulting retraction
of tendon ends
Technique
repair (Finger semi flexed)
22

·REPAIR OF PRACTURED PATELLA
A
B
Lateral deep şutures
kangaroo tendon(ovo a
Ing joint cavity Tearın
fascia closed with catgut)
Repair of ununited
fracture of patella by
fascia lota sumps
Incisions
Per Homes
D
Fragments held in position
by wire passed threrill
holes Torn edges closed
with cotout
Patella encircled by deep
sutures of kangaroos tendon,
gut or Suk Tom edges closed
with catgut
25

·REPAIR OF RECURRENT DISLOCATION OF PATELLA Normal position of patella TPM A Deformity and incision 314 Patellar 1 3 freed up to neor joint cavity Attach ment removed in bony block с Block of pone with pateller lig detached New site being chiseled OUT Before Operation After operation "Patella, D First block 17 new site Second block in serted in bed of first Periosteumn sewed over to hold blocks in place 24

·OPERATIVE TREATMENT OF BUNIONS
PORTER
Deformity
with portion of
bone removed
Inasion
Suture in place
to close
capsule
B
MAYO
B
Flap sutured
'into joint
Bone removed
Metatarsa A
head partly ex
cused' Capsular
flap ready for
interposition
Closure
с
To Jones -
27

·REMOVAL OF SEMILUNAR CARTILAGE
Skin incisions
Tourniquets
applied
A
B
Towels
clipped to
skin edges
Knee flexed over
end of table
Patellar ligament
and fat pad
retracted
Joint manipulated
with patients foot
between kneesi pf
sungeon
Jant capsule
opened between
clamps
Medial meniscus
dissected from
head of tibia
Suture of capsule
fascia and skin
Use of special
knife (Love Breck)
Theptand
26

·OPERATION TOR CONGENITAL DISLOCATED HIP Tom Jones Exposure showing position of head on side ofilium OPEN REDUCTION C в Opening capsule from below and exploring extent of acetabulum Incision 15mith Petersen Reduction with leg in marked abduction SHELVING OPERATION FOR BREDUCIBLE HIP Chr.se! Shelf E Firse layer of borry shelf turned down from ilium Section with le 172 abduction and traction Reinforcing second layer of shelf with struts and cancellous bone taken from X 29 ·OPERATIVE TREATMENT OF BUNIONS (NO 2) 7013 KREUSCHER Reflection of skin and bursal flap Chisel removing exostosy Incision stos B Deformity Bone removed Bursal flap Roughened surface of bong rasped and covered with bone wax E Tendon nestored to its bed Flap shortened Ext hallucis long tendon elongated Padded tongue depressor reattacheap Postoperative splint

·AMPUTATION OF THÇ DIGITS
VETACARROCHA CSAKECUATO AND AMPUTATION TO THE
METACARTAL HEAD
Incisions
Skin
urs
INTERPHALAIVAI DISARTICULATOT
Tendons les 127 for suture
Rube
tur
Plan Sacrare
Amputation
phalanx Madian and
lateral incons wh
long antenzor Elopi
DISARTICULATION OF THE TRES
bly
Sutuskan flar
Amptabanc
2 fire bu
17° sons for removal
o srdyduol toes
31

·SURGICAL TREATMENT FOR PARONYCHIA AND FELON PARONYCHIA Subepithelial abscess facute stage) More advancedrun around Abscess opened for drainage Subungual abscess (fully developed paronychia) Evacuation of Pusby blunt Separation of skin from nail root Incision Bilateral incisions for rtione extensive removal of root (Closed space) Floating portion of nail root cut away with scissors Prepard FELON Incision into closed space for drainage of abscess Necrosis of bone Removailof sequestrum in neglected case 30 ·AMPUTATION FOR GANGRENE OF LOWER EXTREMITY Incision Anterior Lateral B Incision to deep fascia E Sagittal section thru stump Deep vessels isolated with finger and separately! Pigated clánip on geriu supr Fenus dinded with saw after elevation of peprosteum Stump with F drain's 33 ·AMPUTATION OF FOREARM (Incaions for equal skin and fascialflap Skin and fasaal) flaps retracted deep flexors and exten sors cut circularly Muscle flop of supert flexors to cover bone ends A Anterior Lateral posterior Saw cut Shepen Interosseous Septum divided Banes cut thru with saw Periosteur Incised C Large, nerves pulled down injected ond cut off D \A inch of periosteum Temoved and ends of bones rounded Superf flexor muscle Flap sutured to deep. G fictors and extensots F E Man vessels clamp and ligated. Small bleeders picked up after removal of tourniquet Rubber-tissue! blood drain Closure of foscia and skin with interrupted sutures 32 ·AMPUTATION FOR GANGRENE OF LOWER EXTREMITY Jones Inchor Anterior Lateral Incision to deep fascia E Sagittal section thru stump Deep Vessels isolated with finger and separately ligated Sampon geriu supr Fenuto dinded with saw after helevetion of preprosteum Stump with drain's 33 ·THORACOPLASTY Incisions Posterior Anterolateral Showing extent of rib resection (2 stages) Posterior Show ing exterit of rib resection (3 stages) Where further section 13 required Operative field Rib segments removed Intercostal nerve, 13oloted injected and crushed with forceps 17 Field of opera tion thru anter lateral incision Ribs sectioned at costochondral junction Cross section (After complete thoracoplasty) Torr To en 34 ·SURGICAL TREATMENT OF LUNG ABSCESS T Joves A Incision over site of abscess Examination through C incision in endothoracic fascia to determine pres ence of adhesions Operative field after removal of segment of one rib Exploratory incision made through periosteal bed Abscess localized by aspiration of pus 'Cautery incision into abscess for drainage E Packing in troduced to promote ad hesions where no adhesions are found (Two stage operation) D 35 ·SURGICAL TREATMENT OF ACUTE EMPYEMA A Fonts A OPEN LIFTHOD B Beriosteum freed from mb Increion Rib resected Incision being made into pleural cavity Trorar CLOSED METHOD Finger carefully removes fobrin OLS Tasses 3 Catheter inserted Drainage tube 177 position D с Catherer Ewxed in position 36 ·SURGICAL TREATMENT OF ACUTE EMPYEMA Incision show ing fistula ond extent of cavity Loung Cross section of chest before operation Cavity deroofed Muscle flap covering site of bronchial fistulae Rib's resected Area of thick ened plevra to be removed shown by dotted line Complete closure Wound left open Skih margins turned sin Cross section of chest after operation obhteration of cavity showing complete Toe Jones 37

·CLOSED METHOD
SURGICAL TREATMENT OF
ACUTE EM PYEMA
Tom Jones
OPEN METHOD
A
B
Periosteum
freed from
mb
Incision
Rib resected
Incision
being made
into pleural
cavity
Trocar
Finger carefully
removes fibrın
ous inasses
B
Catheter
inserted
Drainage tube
in position
Drainage tube
Catheter
fixed in
pouition
36

·CLOSURE OF RECTUS INCISION
Suture anchored at lower
angle of ext rectus and
then passed thru peritoneum
A
Suture continued as
running statch closing
peritoneum and
post rectas fascia
B
Double
Placing Figure of 8
tension sutures
of Silkworm gut
Closure of ext rectus
fascia tied at conclusion
to anchor-suture
D
permitt
respiration
Beginning
closure
Pin
Anchor future
Tension sutures
tied loosely
Jonego
39

·INCISION AND CLOSURE OF WOUNDS Scratch marks to act cas guide to accurate skin closure Holding skin tant as incision is made to facilitate accur ate technique Blood vessel ex posed and isolated before division Times Blood vessel divided between clamps which do not include surrounding tissue Mattress sutures which help to evert wound edges Accurate apposition of wound edges with few interrupted sutures 38 ·PARAMEDIAN INCISION FOR LAPAROTOMY Nares Rectus retracted exposing tranşvcrsalis fascia with underlying peritoneum Line of division dotted A Paramedian incision inne incision lation to rectus inuscle (Extension dotted) Nerve supply of rectus shown at right Dividing antemor sheath E Cidsure of ant sheath rectus We of Douglas Retráction of wound Closure of trans fascia and peritoneum Diagram showing relationships in cross-section 41

·THE LOW MIDLINE INCISION
A
Incision
Inverted Yincision of
peritoneum at lower ongle
to avoid injury to bladder
Splitting rectus sheath
to provide two layers for
closure Diagram in section
showing structures in
cluded in continuous
catgut sutures
E
Beginning closure
of post rectus sheath
and peritoneum
Tension sutures in position Closure
of ant rectus sheath begun Section
shows figure of 8 tension suture
Skin
closure
40

·OPERATION FOR TORTICOLLIS
A
Deformity
with
incision
Insertion af
sternomastoid and
other fibrous
adhesions severed
F
Steromastoid
Tetracts Under
lying muscles
exposed
Subcutaneous suture
Overcorrection
with cast
Skin closure
43

·ABDOMINAL INCISIONS
CONSERVING INNERVATION
OF THE RECTI
BEVAN
(Gall bladder on right
Side spleen on left)
Initial incisions and
nerve supply
Bevan
Sloan
Réctus
Post. sheath
PFANNENSTIEL
SLOAN
Pfannenst
Ant
sheath
Optional
levels post
sheath
Shepard
Transversalis
fascia
42

·Section thru carbuncle SURGICAL TREATMENT OF CARBUNCLE с Complete fuccision B Stellate incision Undercutting flaps Packed with gauze D A Gridiron incision/ (Maes) Deep fascia Fat E Crucial and double crucial incision Tre Popes Excision of necrotic tissue and subsequent approximation by adhesive (Livingston) 45 ·SUBTEMPORAL DECOMPRESSION Temporal inuscle split and retracted Bone forceps enlarge drill opening in skull Dura still intact B A Site of inasion showing relation Ship of brain and temporal Blceding con trolled ty fin ger presúre as scalp is inced artery Temporal artery ligated E Dura Divided Note ligation of mid meningeal art Separate cos ure of temporal muscle and galea a poneurotica F D Dure lifted from brain by hook and incised Skin closure Tom Jones Ado Froofahm 44

·or macroglossida
PARTIAL RESECTION OF THE TONGUE
RESECTION OF LATERAL HALF OF TONGUE
FOR MALIGNANCY (WHITEHEAD)
Neoplasm
Lateral traction
sutures
Tongue split into
halyes from up to one
inch beyond growth
Lingual
clamped
Cut margins
approxmated
with sutures
Diseased half
amputated
RESECTION FOR NON MALIGNANCY
Clephant
Chronic ulcer
47

·OPERATIVE TREATMENT OF PILONIDAL SINUS LAHEY Incisions Bridge of skin and fat dis placed to midline B Block excision of sinus with parallel lateral incision Pilonidal sinus or cyst Resulting defect packed with gouze, or sutured COLP hull ocey Dressing tid exerting pressure on suture line Mattress sutures thru undermined skan and fat and sacrococcygeal ligs B Mattress futures tied Skin approximated and sutunzends left long 46 ·THYROIDECTOMY Tom Jones Pyramidal lobe A Incision (Passing thru skan fat fascia and platysma) Elevation of lobe and isolation of lateral vein Retraction of Sternothyroid sternohyoid and Sternomastoid muscles Rec laryngn Division of sup pole and suspend bory lig с Sectional view showing rotation trachea and line tresection(dotted) Parathyroid' Jug vein Resection completed and Remnant sutired Reconstruction of isthmus to filin sternal hallow 49

·TONSILLECTOMY
Tonsil loosened
in fossa with
dissector
Mucous membrane
incised along pillar
margins
E
Uvula held
out of way
by suction
tube
KI
Ordinary methods
of hemostasis
Snare appuied
Suturing
H
Removal of
tonsillar remnant
at lingual border
Packing

·SCALENUS ANTICUS SYNDROME
*
Skin
17C2910n
Transv
scapular ves
clamped for
ligation and
division
Root of brachial
plexus and subclavian
y artery before and
after cutting ant
scalenus
muiscle
Dropped rib
Phrenie n lying on thin
art sheath of ant
Bcalenus in
Shopardy
Platysma
and skin
Sutured
Ant scalenus divided
ncluding its thick
posterior sheath
51

·TRACHEOTOMY Incision for high operation Thyroid gland High Tracheotory Pretracheal fascia incised at level of cricord cart Cricoid hooked up to steady trachea Incision for low operation Trachea First 2 or 3 rings divided-cutting outward Low Tracheotomy Vessels, ligated and cut as they appear Thyroid gland rétracted upward Thyroid gli retracted downward (Low site not advised for childrenencroaching large vessels thymnus etc) Edges trimmed for wal opening (Digby) Tape Cut edges of trachea stitched to skin or tracheotomy be introduced Opening to be kept covered with gauze Shepard 50

·LIGATION OF VARICOSE SAPHENOUS VEIN
SARI 14
Vein separated from
postcrior sheath by
blunt dissection
B
Incision
le inch beios
Fouparts lig
Branches and
accessory
veins ligáted,
C
Proxinal end
doubly ligated
Distal end
injected
G
F
Ligature placed one
inch below and vein cut
H
Vein ligated
below puncture
53

·POPLITEAL ANEURYSM Diagrammatic Sections Tibialn Poplit'l v Incision Tibial n Sac Popliteal artery Popliteal a arid sac ANEURYSMECTOMY Very short segment of artery resected with sac Double ligature proxendi Closure fascia & skin Poplitiv Tibial n Penrose drain Provisional control Shepard DOM ENDO ANEURYSMORRHAPHY Obliterative (Metas) Suture of all vessel openings and plication of sac wall Ligatures proximal and 'distal to sac Suture of coll ateral ves open ings Optional plication of sac and "ligation of popliteal v (Red) W 52

·APPENDECTOMY
A Incision
through mght
rectus permit
ting sploration
of abdomen
Ligation of
mesoappendix
B
(x=M°Burney
incision)
F
Purse (string
in position
H'Inverting
stump
D Crushing point
of ligation
Division
between
clamps
I Reinforcing
Suture
E Ligature applied
Suture line
covered by stump
of mesooppendu:
55

·LIGATURE TECHNIQUE METHOD FOR PLACING LIGATURES IN REGIONS DIFFICULT OF ACCESS (Printy-Grant) B Assistant Surgeon Ahapter Hands crossedquare knot E F 54

·LIVER SUTURES
Combined
catgut
suture and
gauze
tampon
Marginal wound closure
by magnesium plates
B
Simple
Relations of liver to ribs and
surrounding structures
suture
Suture thru en--
tire thuckness
of margin
of liver
D
E
Mattress
suture
Are Jores
z
F
Parallel sunken strands
of catout being placed
Transverse
_utures in position
Closure completed
57

·SPLENECTOMY B Paramedian incision with Kocher extension А Right hand inserted to mobilizę spleen from phrenic and posterior attachments D Vasa brevia ligated and gastroşplénıç omentum divided Lesser Spleen reflected medianward and perit cav tail of pancreas separated from pedicle E Vessels of pedicle ligated fin segments F Stump of pedicle covered with omental fat and bleeding points caught with Stitches Abdominal closure without drainage 56 ·CHOLECYSTECTOMY A cystic duct Isolating ond artery by passing neck of gallbladder fórceps behind Live Systicart Systic duet B Gall bladder elevated by forceps on fundus traction made on pouch defining cysuc duct Gallbladder dissected upward Split rubber drain tied in position Cystic duct and artery doubly, clamped and division made between clamps Divided cystic duct and art Bed of gallblodder covered by suturing perntoneal flaps 'D 59

·CHOLECYSTOSTOMY
Incisions for
Pall bladdeposing
Gall bladder elevated
and incision made
in fundus
Calcul.
removed
Tube anchored, Purse string 2nd purse
(May be included suture stringsuture
inl.spurse stml с
1. Jones
Gauze
drain
D
Fundus anchored
to peritoneum and
aponeurosis
Alternate
method
Gall bladder
not anchored but
allowed to drop
back in abdomen
58

·OPERATIONS ON BILIARY TRACT (No 2) Dinct Gatewoods casc HOPATICODUODENOSTOMY Postenor and lateral sutures placed duodenum Ehepatic duct incised Modified Direct W I Mayo) Flap from crescentshaped incision Past and latri sutures T tube Ant sutures Plastic (Walton Taloussano Flap sutured to liver capsule Indirect utenckel) Duod opening closed around tube Long flap Witzel duodenostomy Exposed tube to be covered with adjacent tissues & ginentur Thepend Flap sutured over tube to duodenum & duct (Tube removed after epithelial outgrowth has lined new canal) 61 ·OPERATIONS ON BILIARY TRACT (No 1) SUTURE OF THE COMMON DUCT AFTER REMOVAL OF STONE Utilizing stay Sutures (Printy! A Incision T tubel 2C remove stone Simple thru and thru Purse String (Mayo Robson) REPAIR OF INJURIES TO DUCT (with or without drainagel Partly severed (Mc Arthur) Completely severed Partial structure (Kehr) (Heineke Mikulicz +*+-Catheter end turned principle) back PH Incision with Catheter extend, into duodenum suture of posterior wall Suture of anterior wall Dhepa 60 ·OPERATIONS ON BILIARY TRACT (No 2) Direct Gatewood case HEPATICODUODENOSTOMY Posterior and lateral Sutures placed duodenum & hepatic duct incised Modified Direct IWJ Mayo) Flap from 'crescent- Post andil latrl sutures lilly shaped incision Tube Ant sutures Plastic (Walton) Flap sutured to liver capsule Indirect (Jenckell Duod opening closed around tube Long) flap 1 Witzel duodenostomy Exposed tube to be covered with adjacent tissues & gimentum The pend Flap sutured over tube to duodenum & duct (Tube removed after epithelial outgrowth has lined new canal) 61 ·OPERATIONS ON BILIARY TRACT (No 1) SUTURE OF THE COMMON DUCT AFTER REMOVAL OF STONE Utilizing stay Sutures (Printy! B A T tube Incision to remove stone, Simple thru and thru Purse String (Mayo Robson) REPAIR OF INJURIES TO DUCT (with or without drainage) Partly severed (Mc Arthur) Completely severed Partial stricture (Kehr) (Heineke Mikulicz +*+Catheter end turned principle) /back Incision Catheter extends into duodenum suture of posterior wall suture of anterior wall Shepa 60 ·END TO-END ENTERO ENTEROSTOMY (DYAS) Joop M covering unprotected triangle with mattress mesenteric stitch Comps in position Line of excisión dotted C First holf of anasto hosis completed by, faattress sutunes tied on inside of bowel E Anastornouis completed by mattress Sutures which are tied outside anvert ing bowel wall Line of anas tomosy covered by omental patch Anaslomos13 reinforced by second line of mattress sutures 63 ·ENTEROSTOMY des un cotulit. WA А Inc $ion (Alternate incision hown by dotted l ne) с B Burying tube n wal of int t ne Method of intest nef opening rt on of cathet Inse ton of tube The Lernbert Suture Complet on of el ure by con tinu s serosa Sutu A row shows fuxat on oft be by milestih E D Ston Ivew of completed oprton 62

·POSTERIOR GASTROJEJUNOSTOMY
unum
jejurist
Duodeno
angle
Stomach crown thru slit meso
colon camped & brady for approx
imation with fold of jejunum
Proposed incisions shown in dotted
Als
Posterior sero
muscular future placed
Posterior manginar suture
being placed
Stay
line
Kutuses
Diagram
showing
result
C
TTin
Antenor seromuscular suture
Antenor mangınal suture
65

·GASTRODUODENOSTOMY
(FINNEY'S TECHNIQUE)
stomach
Duodanurn and
stornsch clamped First line of sutures being
placed Larson shown by dotted line
First or posterior line of
sutures completed Inner through
and thrush'suture being placed
Stomato
kinua
Stom
Duo
Sectional
w
D
Anteror tuer of sutures nearly completed
Operation completed
Outer line of serommeslar sutures seen
64

·PARTIAL RESECTION OF STOMACH
(POLYA)
Section
removed
odgnum
of stomach end closed by suture, Anastomosis between
loop of jejunum and lower 3g of stomach
opening begun
Tom Jone
B
in anastomosis of stomach
Intermediate steps
and jejunum
Diagram show
ing finished result in section
67

·GASTROSTOMY
(STAMM METHOD)
Stomach
Reinforced
prot
uai
A
B
Ineusion (Alternate incision
shown by dotted line)
Tube fixed in tomach
wall by single stitch
% -
Sectional
View
E
Stomach
C
D
Frst p se string suture
tred "Two others placed
(Diagram) Stomach fixed
to ant abdominal wall
66

·RAAMSTEDT OPERATION FOR
PYLORIC STENOSIS
Incasion and
exposure
Incision on ant surface
of pylorus thru peritoneum
and supmuscle fibers only
Cornell
Suture
Separation of lips of
incision s}lowing
mucosa to protrude
o
Abdominal wound
carefully cosed in
layers
69

·PANCREATIC CYST Point of approach indicated by direction of Gastrocolic omvat growth of cyst (most frequent) Gastrohepatic Post leaf of omentum mesocolon Panc Skin incision in midline or over tumor if contour prominert Cyst aspirated incised and mopped out with spongos Marsupialization Cyst margin Skin Sponges used to prevert soiling abdomen Purse string about drain Perirenal fat RIWW //Wall of //cyst too short to 'marsupial ize Cyst of tail reached thru kidney incision 68

·PARTIAL RISECTION Or COLON
(MINULICZ)
Thu
ofte
of 3252
B
an
Loop of bowel
Seared to ether and brought
out th Touch wourd Nore
fixation to peritoneum and
osao Loop cutowoy efter
5 to 7 days later
Creeplung forcega lightly clamped
septum scut through
4 to 6 dayo
D
Sectional View
C
Figure
suture
After bowel freed from
wound marging opening 13 invočinated
and losed with Lembert sutures

·INTUSSUSCEPTION
Diagram showing
invagination of ileum
into large bowe!
Technique of reduction
by pressitre upon head
of invaginated portion
3
4
Halstead
suture
res
Suture of
Reduction
completed
d stal ileum to ase colon
to prevent recurrence
70

·RESECTION OF THE RECTUM ABDOMINO FERINEAL OPERATION Dowel clamped for division Peritoneum incised Sup Hemorrhoidal art ligated and cut Rectum mobilized BI Proximal end of bowel to be brought out thru left abdominal incision for colostomy Closed distal end of bowel deposited in pelvis and peritoneum closed over it Yw Perineal dissection Drain Coccyx Excised Shrepen? D Levators duvided and parietal pelvic fascia opened F Perineal sound sutured or left Spen with gauze pack Anal end of rectum freed 73 ·SLIDING HERNIA OF THE CECUM Sac opened and post wall incised leaving margin about herniated bowel (Partly extrasaccular) Edges of margin stitched together to cover raw posterior surface of cecum Subperi neal fat cy Sac Nonfusion of meso colon & parietal INTRASACCULAR peritoneum Sac Cecum Cecum Shepa PARILY EXTRASACCULAR Cecum Bowel reduced Purse-string to close opening (large sacs in verted into abdomen) Cecopexy in initrasaccular type Bassını closure of canal (Partly extrasaccular) 72

·Exposure of
NIPIIRECTOMY
Ws
A
Incion
B
crear
after
portally free
Ing frpinfo.sy
capsule
Cross-section
thri incision
Showing relation
of structures
Kidne
Vert
Mobl ext obd
Moblent abd
M trans abd
Alternatc method
Vessels ligated
separately
E
Ligation of
pedicle en masse
by figure of 8
tronsfixion suture
13 clamps used)
75

·FECAL FISTULA
Inession
Enliptic portion
Surrounds
stuous
tract
Gauze plusy
As aperetora finger
explores relationships
olisundt tract is certain
pleted by scissors,
Ford
Stitch
Neck of tracts exposed
Cut away from intestine
dong dotted line
Operung into
testare closed traversely
74

·REMOVAL or LOW URETERAL CALCULUS
Ureter incised
for removal
of stone
Mucous memb
not included
in suture
Bladder
Incisions
At pelvic brim
(extraperitoneal)
Low pelvic
extraperitonea)
Intramural
(with transposition
of meatus)
Intravegical
(Caulk
method)
Sipas
Cautery used
No sutural
77

·NEPHROTOMY FOR RENAL CALCULI 77 Jonas Shepard- B Nephrotomy incision in lower pole A X ray showing Stones Removal of stones C D Two methods of closure of incision into kidney Fat X ray before dosuré to determine if all stones have been removed F Skin dosure 76 ·OPERATIONS FOR VARICOCELE (OR VARICOCELECTOMY) T7 Uhers VINCENT B Vancocele excised (dotted line) Vas artery and one vein undisturbed Ends of distal lig ature left long Cord exposed and infiltrated Note ext inguinal mng (local anes thesia) Incisions YOUNG Prosomal verous stump Vincent dropped back inin; guinal canal Distal Young stump suspended thru ext ring ARQUICA Redundant veins dissected and ligoted doubly Vas with vein and artery pre gerved B A Cord drawn up into wound and dortos opered exposing veins Ends of vans bound together giving support to testis 79 ·SUPRAPUBIC CYSTOSTOMY AND CYSTOTOMY Median incisions and extensions Peritoneal fold raised from bladder 191.1 Recti separated by blunt dissection CYSTOSTOMYfor drainage Trocar Self retaining catheter YSTOTOMY Bladder incised from below upward Bladder retracted Chepard) CLOSURE Cystostomy Cystotomy 3 layers-, bladder and abdom wall 1 or 2 layers abdom wall Preves drain Drevesical drain 78 ·OPERATIONS FOR VARICOCELE (OR VARICOCELECTOMY) VINCENT B Varicocele excised (dotted line) Vas artery and one vein undisturbed Ends of distal 18 ature left long A Cord exposey and infiltrated Note ext' inguinal ring thesia) Incisions YOUNG C Praxamal venous stump Vincent dropped back inin guinal canal Distal Young stump suspended thru ext ring nous Redundant veins dissected and ligated doubly Vos with veiñ and artery pre served Р Cord drawn up into wound and dortos opered exposing veins Ends of veins bound together ging support to testis 79

·HYDROCELE
OPEN OPERATIONS
Tunica trimmed away
Hemostatic stitch about
remaining mongin
1
Optional
incisons
谈
2 WINKELMANN
3 ANDREWS- Testicle pushed through
small opening high in sac
Sac everted upon cord
Tunica turned inside out
and stitched posterior
to cord and testis
INJECTION METHOD
Massoge
of scrotum
C
b
Aspiration
OF Fland
Injection
of irritant
80

·CIRCUMCISION
Clamp to
protect
glans
Retracted
outer layer
Retracted prepuce
cut off in line parallel
with corona
Inner layer trimmed to
within one cm of corona
Alternate stitches of layers left long
to include strip of vasalıned gauze
Desired result
partly covered
glans
SECOND
METHOD
Probe
Shepard
Cut
Adhesive
Dorsal split (Continuous
suture of layers!
Vasalıped
çauze dressing
If adherent
prepuce separated
'frorn glans
81

·OPERATION FOR UNDESCENDED TESTIS (MCKENNA) Incision B Cord and testacle freed and gubernaculum severed А Gub C Grooved director introduced between vaginal pentoneum and cord Cond freed by blunt dissection E Strapping vagingl peritoneum from cord H Gubernaculum anchored into fascia lata of thigh Grasping guber naculum which will be drawn thru scrotal rision F Preparation of scrotal SOC To 82 ·HALSTED OPERATION FOR INDIRECT INGUINAL HERNIA Edge of Mattress sutures in position to unité int oblique s conjoined tendon to cremaster muscle int oblique and conjoined tendon sutured to Pouparts lig ro Vones Ext ablica EXE oblique Aponeu rotic flaps of ext oblique overlapped by Free margin of upperflap of ext' oblique united to lower flap D mattress sutures C 83 ·BASSINI OPERATION FOR INDIRECT INGUINAL HERNIA Internal oblique Incision Hernial sac opened and examined with finger Int ring Ext Sad Fligated Splittıno aponeuro.is of ext oblique Alternate method Suture placed above cord Aponeuros [Taps overla Subcutaneous fat sytured with catgut Deгр. Sutures of chromicized catgutor kangara tendon approx imating int cbl and tnansversalis to poupart des Split apon eurosis of ext obl closed with running suture TJone 84 ·METHODS or REPAIR IN LARGE UMBILICAL HERNIA A Transverse overlapping of aponeurotic Flaps by mattress sutures Free edge of upper flap secured by continuous suture Incisions Elliptic transverse Elliptic vertical Lateral Overlapping method 5 Transverse overlapping by two tiers of Inattress sutures (Vertical skun incision) 85 ·REPAIR OF FEMORAL HERNIA A Incision с Contents of Sac reduced Sac freed by blunt dissection Purse string Pouparts dig Closure of femoral opening (Two methods) Bassini D Sac transfoxed and tied 86

·AN OPERATION FOR POSTOPERATIVE
VENTRAL HERNIA
(JUDD METHOD)
B
C
Ազի
Incision
surrounding
old scar
Mattress sutures in position
preparatory ta overlapping flaps
They
square flot
Mattress sutures tred
E
D
3116
Peritoneal surface
Sutured to aponeirosis
Continuous suture
completes reconstruction
of abdominal wall
87

·REPAIR OF FEMORAL HERNIA A Incision с Contents of Sac reduced Sac freed by blunt dissection 1.8 Purse string Pa oupa Closure of femoral opening (Two methods Bassini D Sac transfixed and tied Tin Thes 86 ·MAMMARY ABSCESS Premammary - subaredar subcutancous Mammary (of gland proper) Retromammary Mammary (Shield Radiating incision over abscess Finger introduced to break fibrous,pan titions of abscess Premammary Srin incisions radiating from nipple Usually no drain Mammary or Retromaminary (Desmorest Counter openingmade over tip of inserted clamp Perforated drain Skin incision Gland everted abscesses opened Primary Incision sutured Drains anchored Shepard) 89

·RADICAL AMPUTATION OF THE BREAST
B
ecc malakin
DV:-
CAS.cz
e) et
mere
с
2 et son
! لا تعمم
preot mic cu
from comeco.
2.chven
detc.ss
recla
E
COS
Completes
cscctum
The
88

·MAMMARY ABSCESS Premammary foubarrolar subcutaneous Mammary (of gland proper) Retromammary Mammary IShield Radiating incision over abscess Finger introduced to break fibrous, parul titions of abscess Premammary Skin incisions radiating from nipple Usually no drain Mammary or Retromammary (Desmorest) Counter opening made over tip of inserted clamp Perforated drain Skin incision Gland evertedabscesses opened Primary incision Sutured Drains anchored Shepard 89

·REPAIR OF PERINEUM
HEGAR
CLARK
EMMET -
STUDDIFORD
B
Shepard
B
+T*
go

·EPISIOTOMY
Incision
Surgical
Anatomy
B
Urogenital
trigonum
Repair
Levator
sutured
Sphincter
Levator
Vaginal
Sutures placed
Trigonum
suitured
Second
Method
One suture
row including
all layers
Skin suures
left
long.
118
Finger
in rectum
Shep a
91

·SURGICAL ANATOMY OF THE UTERUS
Retroversion
1 st
degree
Retroversion
2nd degree
Retrofleaon
K
-Uretersale
Normal
Umb
Prolapse
Cec 1917
Ut
apēuingur 811
Biedler
Syn
Tube and ovary
Pelvic organs of
female as seen thru
midline incision
92

·HYSTERECTOMY (CURTIS) Atritoneum dissected slightly downward Bunt dissectionof peritoneum fallowed by double clamp, ing of tubes round ligament and upper part of broad ligament Uteru Pestled upward Clamps placed on uterrte arteries with grasp including small portion of uterus *Amputation begun с Division close to 17met clampand ligation E Cervical stump brought together by sutures Covering of raw surfaces begun B Body of uterus hos been removed by shghtly concate incision Ligatures in position F Perstonization completed 93

·SURGICAL ANATOMY OF THE UTERUS
Retroversion
13t
degree
Retroversion
2nd degree
Retroflexaon
K
K
Normal
Umb
Prolapse
1
*
more
Cecin
re
Homola
Ut
afếumsu an
Syrr
Tube and ovary
Pelvic organs of
female as seen thru
midline incision
92

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·VAGINAL HYSTERECTOMY
DODERLEIN KRONIG GRAVES
3
Adhexa tied off
with mass
i ligatures
2
Opening utero
vesical space
Bladder above
1
Stripping back bladder thru
transverse incision at junction
of cervix and bladder
Peritoneum and
broad ligs sewed
to vagina
Broad
ligaments
divided
Parametruthland
post vag wall
divided
Closure
94

·REPAIR OF RECTOCELE
Blunt dissection
of fascia from
vaginal cosa
Diagrama
redcoche
A
Inçusion thru
vaginal mucosa only,
preceded by remove
of small strip of mucosa
Placing purstag
suçure which passes thru
vaginal mucosa and fascia
Closure
E
Fascia united
oblicerating
rectocele
Flaps being
trimmed
TG Jones
town for Curr.
97

·Portian remo
SALPINGECTOMY WITH DEFUNDECTOMY
FALLS
To Jones
B
Closure of fundus with
Infolding of round ligaments
Tubes exasea
wath wedge
shaped section
of tundus
Bla
Section
Fold of bladder
utilized for
pemtonization
Blad
E
F
Operation completed
96

·REPAIR OF VESICOVAGINAL FISTULA
Closure by sutures
of silver wire
SIMS
resicovaginal
High fistula
Types
Erstulae
Edges of
fistula trestened
Tract inverted
Bladder mobilizes fistula
closed by purse string suture
Fistulous track
dissected Two methods
a closure by lembert
suture shown
Separate closure of
fascia and vaginal
mucosa
99

·REPAIR OF CYSTOCELE ADVANCEMENT OPERATION Adapter from Cutz Diagram of cystocele Bladdet freed by blunt dissection Fascia separated from vaginal flaps Vaginalflaps trimmed and united by sutures which grasp underlying fascia With bladder elevated fascia is united by sutures which anter uterus E Closure 98 ·ETHICON SUTURES STRONG SUPPLE SVOOTII UNIFORM HEAT-STERILIZED JOHNSON & JOHNSON began producing surgical sutures in 1887 Our experience of more than half a century has led us to the production of what thousands of surgeons in all parts of the world consider the most dependable catgut ever devised - Ethicon Non-Boilable Catgut Sutures Our scientific staff includes the most capable men available, who devote their entire time to experiment and control in our laboratories in the United States, England, and Australia Absolute sterilization by heat without impairment of tensile strength is the daily production standard of Ethicon Non Boilable Catgut Sutures As taken from the sterile tubes they possess more tensile strength than is required to ligate the largest human blood vessel or to suture the densest human tissue Ethicon Non Boilable Catgut Sutures are produced by exclusive procedures from the raw material to the final stage of packaging and inspection in our laboratories They are supple smooth and uniform ·RECTOVAGINAL FISTULA GOFF Larse high opening Rectum sutured Incision to mobilizer rectum Fascia and vag mucosa Sutired of fistulae Insphincter zone Types il converted into complete laceration DAVID Tract dissected down to rectal mucosa Rectovaginal septum Vaginal nucola resected Anus Tract friverted into rectum and ligated vag Repairof perineum Sphincter Purse renforcing string utures Nepais Rect 100 ·INDEX TO ILLUSTRATIONS PAGE 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 Surgical Treatment of Acute Empyema Incision and Closure of Wounds Closure of Rectus Incision The Low Midline Incision Paramedian Incision for Laparotomy Abdominal Incisions Operation for Torticollis Subtemporal Decompression Surgical Treatment of Carbuncle Operative Treatment of Pilonidal Sinus Partial Resection of the Tongue Tonsillectomy Thyroidectomy Tracheotomy Scalenus Anticus Syndrome Popliteal Aneurysm Ligation of Varicose Saphenous Vein Ligature Technique Appendectomy Splenectomy Liver Sutures Cholecystostomy Cholecystectomy Operations on Biliary Tract (No I) Operations on Biliary Tract (No 2) Enterostomy End to End Entero Enterostomy (Dyas) Gastroduodenostomy (Finney s Technique) Posterior Gastrojejunostomy Gastrostomy (Stamm Method) Partial Rescction of Stomach Polya) Pancreatic Cyst Rammstedt Operation for Pyloric Stenosis Intussusception Partial Rescction or Colon (Mikulicz) Sliding Hemia of the Cecum 54 SS 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 ·INDEX TO ILLUSTRATIONS PAGE 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 Suture Technique (No 1) Suture Techruque (No 2) Suture Technique (No 3) Suture Technique (No 4) Closure of Skin Defects Resection for Epithelioma of Lip Operations for Harelip Single Cleft Skin Grafting-Inlay Grafts Skin Grafting for Burn Contracture Treatment of Burn Contracture of Axilla Skin Grafting--Free Full Thickness Grafts Full Thickness Gract with Sliding Flap Skin Grafting-Split Grafts Delayed Pedicled Flap Skin Grafting-Sieve Graft (No 1) Skin Grafting--Sieve Graft (No 2) Ideal Treatment of Lacerated Wound Immediate Treatment of Crushing Injury of Foot Technique of Nerve Suture Nerve Suture Phrenic Neurectomy Tendon Sutures Tendon Lengthening and shortening Repair of Recurrent Dislocation of Patella Repair of Fractured Patella Removal of Semilunar Cartilage Operative Treatment of Bunions Operative Treatment of Bumons (No 2) Operation for Congenital Dislocated Hip Surgical Treatment for Paronychia and Felon Amputation of the Digits Amputation of Forearm Amputation for Gangrene of Lower Extremity Thoracoplasty Surgical Treatment of Lung Abscess Surgical Treatment of Acute Empyema 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

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·INDEX TO ILLUSTRATIONS PAGE 73 74 75 76 77 78 79 80 81 82 83 84 85 86 Resection of the Rectum Fecal Fistula Nephrectomy Nephrotomy for Renal Calculi Removai of Low Ureteral Calculus Suprapubic Cystostomy and Cystotomy Operations for Varicocele (or Varicocelectomy) Hydrocele Circumcision Operation for Undescended Testis (McKenna) Halsted Operation for Indirect Inguinal Hernia Bassını Operation for Indirect Inguinal Hernia Methods of Repair in Large Umbilical Hernia Repair of Femoral Hernia An Operation for Postoperative Ventral Hernia (Judd Method) Radical Amputation of the Breast Mammary Abscess Repair of Perineum Episiotomy Surgical Anatomy of the Uterus Hysterectomy (Curtis) Vaginal Hysterectomy Amputation of the Cervix Uteri Salpingectomy with Defundectomy Repair of Rectocele Repair or Cystocele Repair of Vesicovaginal Fistula Rectovaginal Fistula 87 88 89 90 91 92 93 94 95 96 97 98 99 100

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