A System of Operative Surgery Part 46

=Snellen's suture method.= The object of this operation is to pa.s.s sutures through the lower lid from rather above the apex of the eversion out on to the cheek, so that when tightened they draw the lid up into position. The inflammation which occurs around the sutures leaves a permanent band of cicatricial tissue which continues the action of the sutures after they have been removed.

[Ill.u.s.tration: FIG. 148. SNELLEN'S SUTURES.

A B

A. A suture in position.

B. The suture tightened.

=Indications.= Snellen's sutures are useful in moderate degrees of the senile form of ectropion in which there is not much thickening of the lid margins. Although the results are satisfactory in carefully selected cases, the operation is attended with considerable pain and is very liable to be followed by a marked inflammation along the st.i.tch tracks; indeed, the final results are not very satisfactory unless some inflammation does occur.

=Instruments.= Two, and occasionally three, sutures of thick silk armed at either end with 3-inch straight needles.

=Operation.= A general anaesthetic is desirable, although not absolutely necessary. The needles belonging to each st.i.tch are inserted about 3 millimetres apart, from the conjunctival surface above the apex of the everted lid, and after pa.s.sing deeply near the lower cul-de-sac on the posterior surface of the tarsus, they are brought out on the cheek low down and tied over a piece of drainage tube. The loops, when drawn tight, draw the lid margin inwards (Fig. 148). Two of these sutures are usually required at such a distance apart as to divide the lower lid into thirds. They should be left in place some two or three weeks.

=Fergus's operation.= This operation consists in excision of the apex of the everted lid.

=Indications.= It is a most satisfactory operation for cases in which the lid margin has undergone thickening from blepharitis and for cases of slight senile ectropion.

=Instruments.= Beer's knife, fixation forceps, and sharp-pointed scissors.

=Operation.= Under adrenalin and cocaine, a little solid cocaine being rubbed into the conjunctiva. A strip of thickened conjunctiva and subconjunctival tissue corresponding to the apex of the eversion is removed along the whole length of the lid (Fig. 149). The wound produced is united with sutures. The pull of the conjunctiva, which is st.i.tched to the lid margin, is sufficient to draw that structure inwards into position.

[Ill.u.s.tration: FIG. 149. FERGUS'S OPERATION FOR SLIGHT ECTROPION OF THE LOWER LID. Showing the lines of the incision.]

=Kuhnt's operation= (modified). The object of this operation is the removal of a triangular piece of conjunctiva and tarsal cartilage from the centre of the lower lid, the base of the triangle being placed towards the free margin of the lid so as to produce sufficient shortening of the elongated lid border to hold it in position. The skin of the lid is also shortened by removal of a triangular portion at the external canthus.

=Indications.= It is especially suitable for cases of paralytic ectropion (lagophthalmos) and severe degrees of senile ectropion of the lower lid.

=Instruments.= Lid spatula, Beer's knife, scissors, forceps and sutures.

=Operation.= A general anaesthetic is required.

_First step._ The lower lid being held between the finger and thumb is split in the intermarginal line along the outer two-thirds of its length, and the incision deepened till the lower border of the tarsus is reached. For this purpose some surgeons use a broad keratome instead of a Beer's knife.

_Second step._ A triangular piece of conjunctiva and the whole thickness of the tarsus are removed from the centre of the lower lid, the base of the triangle being towards the free margin of the lid and being of sufficient length to produce the shortening desired to bring the lid up into position (Fig. 150); this is best estimated by making the incision forming the inner limb of the V and overlapping the outer flap until the lid is pulled upwards into position.

_Third step._ A triangular piece of skin with its base upwards is excised from the outer canthus in the following manner (Fig. 150). An incision is made outwards and slightly upwards from the canthus. A vertical incision, twice the length of the preceding one, is made directly downwards from its outer end to the outer canthus, and the lower end of this is then joined by an incision completing the triangle.

The skin marked out by this triangle is then dissected up and removed.

The undermining of the flap formed by the skin and subcutaneous tissue of the outer part of the lid is continued inwards until the flap, when pulled up into place, restores the lid to its proper position.

[Ill.u.s.tration: FIG. 150. MODIFIED KUHNT'S OPERATION FOR SEVERE ECTROPION. _Second step._ The outer half of the lid is split and a V-shaped portion of the tarsal plate removed. The triangular piece of skin at the outer canthus is entirely removed.]

[Ill.u.s.tration: FIG. 151. MODIFIED KUHNT'S OPERATION. _Fourth step._ Showing the sutures in position. The outer part of the lid has been undermined and dissected up. The V-shaped gap in the tissues is sutured first.]

_Fourth step._ The lid is sutured into position. The V-shaped wound in the conjunctiva and tarsus is sutured, the knots being placed on the conjunctival surface with the exception of the suture at the lid border, which is turned the other way, the ends being brought out through the skin of the outside flap, after the latter has been sutured in position, and the two ends tied over a bead. The outside flap of skin is brought up into position by a suture at its upper angle. As the result of this a few eyelashes project beyond the outer canthus; these should be excised.

Additional sutures to hold the flap in position are then inserted. Both eyes should be bandaged after the operation, otherwise the knots in the conjunctiva may rub on the cornea.

=Argyll Robertson's operation.= The operation aims at shortening the border of the lower lid and at the same time pulling it upwards into position by means of a strap of skin and subcutaneous tissue cut from the outer side, the attached end of the strap being formed by the outer portion of the skin of the lower lid.

=Indications.= It is especially useful for paralytic cases, and as a subsequent measure to the VY operation described below for cicatricial ectropion. The operation is likely to be successful if a marked reduction in the deformity is effected by pulling the skin at the side of the outer canthus upwards.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures.

[Ill.u.s.tration: FIG. 152. ARGYLL ROBERTSON'S OPERATION FOR ECTROPION.

_Second step._ Showing the method of shortening the lid and the strap of skin reflected. The upper convex line shows the piece of skin to be removed so that the lid may be pulled upwards into position.]

[Ill.u.s.tration: FIG. 153. ARGYLL ROBERTSON'S OPERATION FOR ECTROPION.

_Final step._ The strap of skin has been sutured in position after pulling it upwards sufficiently to reduce the deformity and enlarging the raw area upwards to allow this to be done.]

=Operation.= _First step._ An incision, 2 millimetres below the lid margin and opposite its outer third, is carried through the skin parallel to the border of the lower lid outwards to the canthus; having reached this point the direction of the incision is changed and it is carried more upwards and outwards till the upper end is on a level with the upper orbital margin. The incision is then carried outwards for about 6 millimetres and again downwards, slightly diverging from the former incision, until it is opposite the lower orbital margin. This flap of skin and subcutaneous tissue is dissected up from above downwards (Fig. 152).

_Second step._ A V-shaped portion is removed from the margin of the lower lid near the outer canthus, the base of the V being of sufficient length to produce the shortening of the lid required when the edges of the incision are brought together.

_Third step._ The strap of skin is pulled upwards to the extent required to replace the lid in position, and sutured there. The raw area must be enlarged upwards so as to accommodate the upper end of the strap. It is better to do this than to shorten the strap, since a firm hold is thus obtained (Fig. 153).

OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION

The numerous operations which have been devised for this condition are divided into two groups: (1) the transplantation of flaps in the neighbourhood of the lesion, and (2) the grafting of skin flaps from other parts of the body. The latter method is usually only undertaken when the employment of flaps from the neighbourhood of the deformity is impossible, as the cicatricial contraction which follows the grafting of flaps from other parts of the body is usually attended by considerable shrinkage and therefore does not yield such satisfactory results.

[Ill.u.s.tration: FIG. 154. VY OPERATION FOR ECTROPION OF THE LOWER LID DUE TO A SCAR. _First step._ Showing incision.]

[Ill.u.s.tration: FIG. 155. VY OPERATION FOR ECTROPION. _Final step._ Showing the lid in position.]

BY THE TRANSPLANTATION OF FLAPS

=VY operation= (Wharton Jones). =Indications.= This operation is useful for cases of ectropion affecting the middle parts of the lower lid, generally due to a scar such as would result from a healed sinus after tuberculous periost.i.tis of the lower orbital margin.

=Instruments.= Dissecting forceps, scalpel, artery forceps, sutures.

=Operation.= The operation is performed under a general anaesthetic. A V-shaped incision, with the apex downwards, is made to embrace the whole margin of the lower lid. The upper ends of the V should skirt the outer and inner canthus and roughly lie over the lower orbital margin, enclosing the scar, the apex of the V falling rather below the orbit.

The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155).

Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary.

=Denonvillier's operation.= This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus.

[Ill.u.s.tration: FIG. 156. DENONVILLIER'S OPERATION FOR ECTROPION OF THE LOWER LID. By reversed flaps at the outer angle. _First step._ The flap B C D is brought down to form the outer part of lower lid.]

[Ill.u.s.tration: FIG. 157. DENONVILLIER'S OPERATION FOR ECTROPION. Showing the operation completed after transposition of the flaps.]

=Instruments.= Scalpel, dissecting and artery forceps, scissors, sutures.

=Operation.= The operation is performed under a general anaesthetic.

_First step._ An oblique incision (Fig. 156), starting from below the inner end of the deformity, A, is carried outwards and slightly upwards for 12 mm. to the point B. From the point B a curved incision B C is carried upwards to and along the orbital margin. This marks out a triangular flap. From C the incision is carried outwards and downwards in a curved direction to D, which is situated about 2 cm. from the external canthus, thus marking out another triangular flap B C D.