Chapter 1 THE ESOPHAGUS 1
ANATOMY 1
PHYSIOLOGY 10
ANESTHESIA FOR OPERATIONS ON THE ESOPHAGUS 11
INCISIONS 11
SPECIAL PRINCIPLES OF ESOPHAGEAL SURGERY 13
ESOPHAGOSCOPY 14
ESOPHAGOTOMY 19
ESOPHAGOSTOMY 22
PERFORATIONS OF THE ESOPHAGUS 22
Suture of Perforation 26
Cervical Mediastinotomy 26
Posteroinferior Mediastinotomy 28
BENIGN STRICTURES OF THE ESOPHAGUS 30
Congenital Strictures of the Esophagus 30
Acquired Benign Stenosis of the Esophagus 32
Corrosive Strictures of the Esophagus 32
Postsurgical Strictures of the Esophagus 37
Inflammatory Strictures of the Esophagus 37
Operative Treatment 39
Esophagoplasty (Heineke-Mikulicz) 39
Partial Esophagectomy with End-to-End Esophago-esophagostomy 39
Partial Gastrectomy for Esophagitis with Stricture 41
RECONSTRUCTION OF THE ESOPHAGUS 42
Intrathoracic Replacement of the Esophagus 42
Extrathoracic Esophagoplasty 42
Roux＇s Method (Esophagojejunogastrostomy) 44
Herzen＇s Method 47
Wullstein＇s Method 50
Birger＇s Method 52
Esser＇s Method 53
Lexer＇s Method 54
Ochsner-Owens Modification of Lexer＇s Method 58
Other Methods 62
BENIGN TUMORS OF THE ESOPHAGUS 62
Local Excision of Benign Tumors 64
ESOPHAGEAL ACHALASIA 65
Bougienage 68
Operative Treatment 70
Side-to-Side Esophagogastric Anastomosis (Heyrovski) 70
Side-to-Side Esophagogastrostomy (Grondahl) 73
Cardioplasty (Wendel) 74
Cardioplasty (Girard) 75
Esophagocardiomyotomy (Heller) 76
Partial Esophagectomy with Esophagogastrostomy (Rumpel,Wangensteen) 79
Other Procedures for the Treatment of Achalasia 80
TRACHEOESOPHAGEAL AND BRONCHOESOPHAGEAL FISTULAS 80
Congenital Esophageal Atresia with or without Tracheoesophageal or Bronchoesophageal Fistula 81
Extrapleural Operation (One Stage) 83
One-Stage Intrapleural Operation 88
Two-Stage Intrapleural Operation 90
Acquired Esophagorespiratory Fistula 93
Repair of Acquired Esophagorespiratory Fistula 94
ESOPHAGOPLEURAL FISTULA 97
Repair of Esophagopleural Fistula 98
ESOPHAGEAL VARICES 99
Tamponade 102
Injection Treatment 105
Ligation of the Hepatic,Splenic and Left Gastric Arteries (Rienhoff) 106
Splenic Artery Ligation (Blain) 109
Gauze Packing of Mediastinum (Garlock) 111
Transesophageal Ligation of Bleeding Varices (Crile) 114
Other Operations for Esophageal Varices 116
ESOPHAGEAL DIVERTICULA 117
Pharyngoesophageal Diverticula 117
Two-Stage Diverticulectomy (Lahey) 121
One-Stage Diverticulectomy 126
Supradiaphragmatic Diverticula 130
Supradiaphragmatic Diverticulectomy 131
Supradiaphragmatic Diverticular Suspension 131
Midesophageal Diverticula 132
MALIGNANT TUMORS OF THE ESOPHAGUS 133
Souttar＇s Intubation 135
Esophagectomy 137
Partial Esophagectomy with End-to-End Esophago-esophagostomy 137
Cervical Esophagectomy with Skin Flap Closure in Two Stages (Wookey) 138
Cervical Esophagectomy and laryngectomy with Skin Flap Closure in Two Stages (Wookey) 143
Cervical Esophagectomy with Replacement by Tubed Pedicled Grafts (Bricker) 144
One-Stage Partial Esophagectomy with Replacement by a Plastic Tube (Berman) 149
Partial Esophagectomy with Low Esophagogastrostomy (Sweet) 154
partial Esophagectomy with High Intrathoracic Esophagogastrostomy (Sweet) 163
Partial Esophagectomy with Cervical Esophagogastrostomy (Sweet) 166
Partial Esophagectomy with Cervical Esophagojejunostomy in One Stage (Sweet) 170
One-Stage Total Esophagectomy with Esophagogastrostomy (Shefts and Fischer) 171
Two-Stage Intrathoracic Esophagojejunostomy (Rienhoff) 174
Artificial Esophagus Formed by a Free Segment of Intestine Covered by Skin (Longmire and Ravitch) 181
Intrathoracic Replacement of Esophagus with Transverse and Descending Colon 185
Repair of Tracheobronchial Defects Produced during Esophagectomy 185
Repair of Small Defects by Patching 186
Repair of Larger Tracheobronchial Defects 186
Repair with Tantalum Mesh Covered by Cutis Graft (Handelsman-Kieffer-Edgerton) 187
Repair by Dermal Skin Grafts Laced with Wire (Gebauer) 188
Repair with Wire Coil Covered by Fascia (Belsey) 190
Repair with Viable Pedicle Graft (Penton and Brantigan) 191
TRACHEOTOMY 192
REFERENCES 197
Chapter 2 THE STOMACH AND DUODENUM 201
SURGICAL ANATOMY OF THE STOMACH 201
SURGICAL ANATOMY OF THE DUODENUM 207
PHYSIOLOGY OF THE STOMACH 210
PHYSIOLOGY OF THE DUODENUM 212
GASTRIC,GASTRODUODENAL AND LOWER GASTROINTESTINAL INTUBATION 212
Peroral Gastric Intubation 212
Nasal Gastric,Gastroduodenal and Lower Gastrointestinal Intubation 214
Levin Tube 214
Bilumen Gastrojejunostomy Tube 216
Bilumen Gastroduodenal Tube 216
Miller-Abbott Tube 217
Harris and Cantor Single-Lumen Mercury-Weighted Tubes 219
Comment on Use of Indwelling Gastrointestinal Tubes 220
PERORAL GASTROSCOPY 221
Peroral Gastroscopy with flexible Gastroscope 222
Peroral Gastroscopy with Rigid-Tube Gastroscope (Jackson) 224
ANTERIOR GASTROSCOPY AND DUODENOSCOPY THROUGH A GASTROTOMY OR GASTROSTOMY STOMA 227
ACUTE DILATATION OF THE STOMACH 227
GASTROLYSIS AND DUODENOLYSIS (FREEING OF ADHESIONS) 228
VOLVULUS OF THE STOMACH 229
GASTROPEXY 231
GASTRIC PLICATION 234
GASTROINTESTINAL SUTURING 235
Interrupted Lembert Suture 238
Continuous Lembert Suture 240
Halsted Interrupted Quilt (Mattress) Suture 240
Purse-String Suture 240
Cushing Suture 242
Connell Suture 242
Parker-Kerr Stitch 242
Through-and-Through U-Stitch 243
Marshall U-Stitch 245
Furrier Suture 248
Simple Overhand continuous or Interrupted Suture (Albert) 248
Lock-Stitch (Glover Stitch) 248
Czerny Interrupted Sutures 249
Enterorrhaphy by a combination of a Continuous Through-and-Through Marginal (Albert) Suture and Interrupted,Gould Inverted Mattress Suture 250
Three-Layer Suture Line 251
Suture Instrument of de Petz 251
Murphy Button 253
INCISIONS FOR EXPOSURE OF STOMACH AND DUODENUM 254
GASTROTOMY 256
GASTRORRHAPHY 258
INCISED AND GUNSHOT WOUNDS OF THE STOMACH 261
GASTROSTOMY 264
Witzel Gastrostomy 265
Intramural Gastrostomy (Submucosal Canal) (Marwedel-Soresi- Partipilo Method) 267
Superimposed Pruse-String Gastrostomy (Stamm-Senn Method) 269
Brunschwig＇s Gastrostomy 270
Kader (Double Linear Plication) Gastrostomy 270
Ssabanajew-Franck (Stomach Cone Transfer) Gastrostomy 272
Kocher＇s Modification of the Ssabanajew-Franck Operation 275
Albert＇s Modification of the Ssabanajew-Franck Operation 275
Hahn＇s Modification of the Ssabanajew-Franck Operation 275
Glassman＇s Gastrostomy 276
Janeway-Depage (Tubular) Gastrostomy 277
Spivack Valvular Modification of Janeway-Depage Tubular Gastrostomy 280
Comment on Janeway-Type Gastrostomies 280
Beck-Jianu (Long Gastric Tube) Gastrostomy 281
Retrograde Bougienage of the Esophagus through a Gastrostomy Opening 284
Comment on Gastrostomies in General 285
OPERATIONS FOR STENOSIS OF THE CARDIA 285
Retrograde Stretching of the Cardiac Orifice from within the Stomach 286
Other Procedures 286
SIMPLE EXCISION OF A PEPTIC ULCER 286
Excision of Ulcer on Anterior Wall of Stomach 286
Excision of Ulcer on Posterior Wall of Stomach 286
Retrogastric Excision 286
Transgastric Excision 287
Cautery Excision of Gastric Ulcer (Balfour) 288
Wedge-Shaped Excision of Ulcer on Lesser Curvature of Stomach with or without Accompanying Gastrojejunostomy 289
Simple Excision of Small Ulcer on Anterior Wall of the First Portion of Duodenum 291
LOCAL EXCISION OF BENIGN GASTRIC TUMOR (INCLUDING POLYPS) 291
DIVERTICULUM OF THE SHTOMACH 291
Excision of Gastric Diverticulum 293
DEVERTICULUM OF THE DUODENUM 293
Excision of Duodenal Diverticulum 294
DUODENOJEJUNOSTOMY 297
OPERATIONS UPON THE PYLORUS FOR ENLARGING ITS ORIFICE 301
Pylorotomy 301
Pyloric Hypertrophy in Adults 301
Congenital Hypertrophic Pyloric Stenosis 302
Fredet-Ramstedt Pylorotomy 302
Pylorodiosis 307
Pyloroplasty 307
Heineke-Mikulicz Pyloroplasty 307
Horsey Modification of Heineke-Mikulicz Pyloroplasty 309
Finney U-Shaped Pyloroplasty (Gastroduodenostomy) 309
Balfour＇s Excision Pyloroplasty 314
Pyloroplasty with Excision of Ulcer (Judd) 316
Comment on Pyloroplasty in General 316
GASTRCENTEROSTOMY 317
Gastroduodenostomy (Jaboulay,1892) 317
Gastroduodenostomy (Rienhoff) 319
Gastrojejunostomy 323
Precolic (Antecolic) Anterior Gastrojejunostomy (Woelfler,1881) 325
Precolic Posterior Gastrojejunostomy 332
Retrocolic Posterior Gastrojejunostomy (Von Hacker,1885) 332
Retrocolic Anterior Gastrojejunostomy 340
Roux-en-Y Gastrojejunostomy 341
Comments on Gastrojejunostomy in General 343
METHODS OF CLOSURE OF DUODENAL STUMP IN GASTRECTOMY OR EXCLUSION OPERATIONS 344
Inversion by Parker-Kerr Suturing 345
Rienhoff Method 346
Closure with Tamponade 346
Closure by Multiple Purse-String Sutures 348
Closure with Ligature and Suture 350
Temporary Duodenostomy 350
GASTRIC AND DUODENAL (PEPTIC) ULCER 351
Complications of Peptic Ulcer 358
Perforation 358
Obstruction 359
Bilocular Stomach or Hour-Glass Contraction of Stomach 360
Hemorrhage 360
Treatment of Peptic Ulcer 363
TUMORS OF THE STOMACH AND DUODENUM 365
Benign Tumors 365
Benign Gastric Tumors 365
Benign Tumors of the Duodenum 367
Symptoms and Diagnosis of Benign Tumors of Stomach and Duodenum 367
Treatment of Benign Tumors of Stomach and Duodenum 367
Malignant Tumors 368
Malignant Tumors of the Stomach 368
Malignant Tumors of the Duodenum 369
Symptoms and Diagnosis of Malignant Tumors of Stomach and Duodenum 370
Treatment of Malignant Tumors of Stomach and Duodenum 371
GASTRECTOMY 371
Partial Gastrectomy 375
Partial Gastrectomy with End-to-End Gastroduodenostomy (Billroth Ⅰ Operation) 389
Von Haberer Modification of the Billroth Ⅰ Operation 400
Horsley Modification of the Billroth Ⅰ Operation 404
Kocher Modification of the Billroth ⅠOperation 404
Von Haberer-Finney Modification of the BillrothⅠOperation 404
Tubular of Staircase Modification of Billroth Ⅰ Partial Gastrectomy with a Variety of Methods of Performing the Accompanying Gastroduodenostomy 406
Comment on Billroth Ⅰ Procedure 409
Partial Gastrectomy of the Median Portion of the Stomach (Sleeve Resection) 409
Segmental Partial Gastrectomy for Peptic Ulcer (Wangensteen) 410
Transthoracic Resection of Esophagus and Cardiac End of Stomach 413
Comments on Billroth Ⅱ partial Gastrectomy 416
Polya Modification of Billroth Ⅱ Operation 417
Polya-Balfour Modification of Billroth Ⅱ Operation 433
Hofmeister Modification of Billroth Ⅱ Operation 433
Original Billroth Ⅱ Partial Gastrectomy 440
Devine Exclusion Two-Stage Partial Gastrectomy 443
Finsterer Partial Gastrectomy with Antral Exclusion of Peptic Ulcer 447
Roux-en-Y Modification of Billroth Ⅱ Operation 450
Results of Partial Gastrectomy 452
Total Gastrectomy 454
Longmire Method 456
Lahey Method 462
Orr Method 469
Graham Method 471
Roux-en-Y Total Gastrectomy 472
Total Gastrectomy with Esophagoduodenostomy 481
Total Gastrectomy with Formation of Substitute Gastric Reservoir 482
Results of Total Gastrectomy 486
Comments on Partial and Total Gastrectomies 486
OPERATIONS FOR PYLORODUODENAL OCCLUSION AND EXCLUSION AND FOR ANTRAL EXCLUSION 489
Pyloroduodenal Occlusion by Ligation of the Pylorus,Accompanied by Gastrojejunostomy 490
Prepyloric Occlusion by Transverse Plication 490
Pyloroduodenal Exclusion by Disconnection (Bier) 490
Prepyloric Exclusion by Disconnection (Von Eiselberg) 490
Devine Operation for Prepyloric Exclusion 490
OPERATIONS FOR HOUR-GLASS OR SADDLE-BAG DEFORMITY OF THE STOMACH 494
Lateral Gastrogastrostomy for Hour-Glass Stomach 494
Kammerer-Finney Gastroplasty for Hour-Glass Stomach 494
Heineke-Mikulicz Gastroplasty for Hour-Glass Stomach 494
Wedge-Shaped Excision for Hour-Glass Stomach 494
Sleeve Resection for Hour-Glass Stomach 496
Operation for Hour-Glass Stomach by Anterior or Posterior Gastrojejunostomy with the Proximal Pouch 497
COMPLICATIONS AFTER GASTROINTESTINAL ANASTOMOSIS 498
Hematemesis 498
Postoperative Gastric Retention 500
Jejunoplasty 502
Leakage form Duodenal Stump 508
Rupture of Abdominal Incision 509
Venous Thrombosis 509
Marginal Jejunal Ulcer 510
Disconnection of Gastrojejunostomy 511
Repair of Gastroileostomy 514
Gastrojejunocolic Fistula 515
Pfeiffer Method of Closing Gastrojejunocolic Fistula 516
Findlay Method of Closing Gastrojejunocolic Fistula 520
Marshall Method of closing Gastrojejunocolic Fistula 523
Gastric Fistula 525
External Gastric Fistula 525
Internal Gastric Fistula 526
Duodenal Fistula 527
Internal Duodenal Fistula 527
External Duodenal Fistula 529
Other Complications 532
OPERATIONS FOR ACUTE COMPLICATIONS OF GASTRIC AND DUODENAL ULCERS 533
Hemorrhage from Ulcers of the Stomach and Duodenum 533
Perforated Peptic Ulcer 541
Closure of Acutely Perforated Peptic Ulcer 545
Nonoperative Treatment of Perforated Peptic Ulcer 548
VAGOTOMY 549
Abdominal (Subdiaphragmatic) Vagotomy 553
Transthoracic (Supradiaphragmatic) Vagotomy 556
Postoperative Complications of Vagotomy 559
Comments on Vagotomy 560
REFERENCES 561
Chapter 3 THE LIVER 565
ANATOMY 565
PHYSIOLOGY 570
LIVER FUNCTION TESTS 575
GENERAL SURGICAL CONSIDERATIONS 584
ANESTHESIA 587
INCISIONS 587
Incisions Used for Transperitoneal Exposure of Anterosuperior Surface of Liver 587
Transperitoneal Exposure of Dome and Anterior Aspect of Right Lobe 588
Transperitoneal Exposure of Lower Lateral Border of Right Lobe 588
Extraperitoneal-Extrapleural Exposure of Extraperitoneal Surface of the Liver 588
Intercostal Subpleural Exposure of Superior Surface 589
Rib Resection for Extrapleural Exposure of Superior Surface 589
Transpleural Approach to the Superior Surface Following Partial Resection of Ribs 589
EXPLORATORY AND DIAGNOSTIC OPERATIONS UPON THE LIVER 589
Exploratory Puncture without Incision of the Chest or Abdominal Wall 589
Needle Biopsy 591
Peritoneoscopy 593
WOUNDS OF THE LIVER 603
PARTIAL HEPATECTOMY FOR REMOVAL OF TUMOR OF THE LIVER 607
V-Shaped Excision of Small Tumor of Edge of Liver 608
V-Shaped Excision of Large Tumor of Anterior Margin 608
Left Lobectomy of the Liver 609
INTRAHEPATIC ABSCESS 612
Pyogenic Intrahepatic Abscess 612
Amebic Intrahepatic Abscess 616
Aspiration of Intrahepatic Abscess 620
Closed Tube Drainage of Amebic Abscess of the Liver 622
Hepatotomy for Intrahepatic Abscess 623
One-Stage Transperitoneal Hepatotomy for Intrahepatic Abscess 624
Two-Stage Transperitoneal Hepatotomy for Intrahepatic Abscess 626
Transthoracic Hepatotomy 626
SUBPHRENIC (SUBDIAPHRAGMATIC) ABSCESS 632
Anterior Extraserous Drainage of Subphrenic or Intrahepatic Abscess (Clairmont) 638
Posterior Extraserous Drainage of Subphrenic or Intrahepatic Abscess (Nather and Ochsner) 639
Comment 642
HYDATID DISEASE 642
Hydatid Cysts of the Liver 651
Surgical Treatment of Uncomplicated Cysts 651
Treatment of Complicated Cysts 655
Postoperative Complications 659
Results of Surgical Treatment 660
Hydatid Cysts of the Peritoneum and Pelvis 660
Hydatid Cysts in Other Locations 662
NONPARASITIC CYSTS OF THE LIVER 663
CIRRHOSIS OF THE LIVER 664
Abdominal Paracentesis for Evacuation of Ascitic Fluid 670
Crosby-Cooney-Lord (＂Button＂) Operation for Intractable Ascites 672
Establishment of New Intraperitoneal Venous Channels in Cirrhosis of the Liver (Talma-Drummond-Morison Operation) 674
Extraperitoneal Omentopexy in Cirrhosis of the Liver 675
Portacaval Anastomoses 676
Splenorenal Anastomosis 679
Anastomosis of Portal Vein to Vena Cava 683
Comments on Portacaval Anastomoses 687
Splenic Artery Ligation 688
TREATMENT OF WOUNDS OF THE HEPATIC ARTERY AND PORTAL VEIN INCURRED DURING OPERATION 689
REFERENCES 690
Chapter 4 THE GALLBLADDER AND EXTRAHEPATIC BILIARY DUCTS 693
SURGICAL ANATOMY OF THE GALLBLADDER 693
SURGICAL ANATOMY OF THE EXTRAHEPATIC BILIARY DUCTS 696
PHYSIOLOGY 700
ANOMALIES AND CONGENITAL ABNORMALITIES OF THE GALLBLADDER AND BILE DUCTS 702
Anomalies of the Gallbladder 703
Anomalies and Abnormalities of the Common bile Duct 708
Cystenterostomy 712
Congenital Atresia of the Bile Ducts 713
Operation for Atresia of the Bile Ducts 715
OBSTRUCTIVE JAUNDICE DUE TO INSPISSATED BILE OR MUCUS IN THE BILIARY PASSAGES OF INFANTS 719
Operation for Relief of Biliary Obstruction Due to Inspissated Bile or Mucus 719
CHOLECYSTITIS AND CHOLELITHIASIS 720
Acute Cholecystitis 721
Chronic Cholecystitis and Cholelithiasis 727
Cholelithiasis 730
Results of Surgical Treatment of Acute and Chronic Cholecystitis and Cholelithiasis 733
CHOLESTEROSIS OF THE GALLBLADDER 733
RECOGNITION OF CHRONIC CHOLECYSTIC DISEASE AT OPERATION 734
CHOLEDOCHOLITHIASIS 735
TUMORS OF THE EXTRAHEPATIC BILIARY TRACT 738
Benign Tumors of the Gallbladder 738
Primary Carcinoma of the Gallbladder 739
Primary Sarcoma of the Gallbladder 743
Benign Tumors of the Bile Ducts 743
Primary Malignant Tumors of the Extrahepatic bile Ducts 744
GENERAL SURGICAL CONSIDERATIONS OF OPERATIONS ON THE BILIARY TRACT 746
OPERATIONS UPON THE GALLBLADDER 752
Cholecystectomy 752
Total Cholecystectomy 756
Cholecystectomy with Drainage of the Common Duct 762
Partial Cholecystectomy with Chemical Destruction of the remaining Mucosa 762
Partial Cholecystectomy with Electrocoagulation of the Remaining Mucosa (Thorek) 765
Postoperative Care of Cholecystectomy Subjects 767
Cholecystostomy 768
Operations for Internal Drainage of the Gallbladder (Cholecystoduodenostomy,Cholecystogastrostomy,and Cholecystojejunostomy) 772
Cholecystoduodenostomy 773
Cholecystogastrostomy or Cholecystojejunostomy 775
Operations for Wounds of the Gallbladder 775
SECONDARY OPERATIONS FOR RECURRING BILIARY TRACT DISEASE 775
OPERATIONS UPON THE EXTRAHEPATIC BILE DUCTS 779
Supraduodenal Choledochostomy an Choledocholithotomy (Exploration of the Common Duct) 780
Transduodenal Ampullary Choledochoduodenostomy 794
Transduodenal Approach for Intraduodenal (Interstitial) Choledochotomy for Calculus 798
Retroduodenal Choledochotomy for Calculus Followed by Choled0chorrhaphy 799
Transduodenal Excision of the Duodenal Ampulla (of Vater) 801
Choledochoduodenostomy,Choledochogastrostomy and Choledochojejunostomy for Irremediable Obstruction in the Distal Portion of the Common Duct 802
Excision of the Gallbladder,Cystic Duct and the Junction of the Main Hepatic and Common Ducts for Tumor,Followed by Hepaticocholedochostomy over a T-Tube 806
Repair of Wounds of the Biliary Ducts 808
Repair of Wounds Due to Surgery 808
Repair of Wounds Due to Trauma 810
Repair of Benign Stricture of the Bile Duct 811
Incision and Repair of Stricture by Heineke-Mikulicz Method 817
Repair by Simple End-to-End Anastomosis 818
Repair by Dissecting out Retroduodenal Portion of Common Duct Followed by End-to-End Anastomosis 820
Repair by End-to-End Anastomosis of the Duct over Temporary Indwelling Tube Other than a T-Tube 824
Repair by End-to-End Anastomosis of Ducts without the Use of Either a Temporary or Permanently Indwelling Tube 827
Repair by End-to-End Anastomosis of the Ducts over a Permanent Indwelling Tube 828
Comment on Repair by End-to-End Anastomosis of the Ducts 829
Repair by Dilation and Tube Implantation of the Duct 830
Bridging Defects in bile Ducts by Tubes (Wilms-Sullivan) 830
Simple Excision of Stricture of the Bile Duct with Implantation of Proximal Segment of Duct into Intestinal Tract 832
Intrahepatic Cholangiojejunostomy with Partial Hepatectomy (Longmire) 841
Use of Pedicle Flap of Stomach (Hoag) 844
Use of Mucosal Flap of Jejunum (Cole) 845
Establishment of an External Biliary Fistula with Later Implantation of the Fistulous Tract into the Intestinal Tract 848
Formation of Temporary External Biliary Fistula 848
Cholecystenterostomy 850
Comments on Operations for Repair of Stricture of Bile Ducts 850
HEPATOSTOMY 852
Internal Hepatostomy 852
External Hepatostomy 853