SUTURE OF THE ABDOMINAL WALL.1

BY CHARLES DAVISON, M.D.,

OF CHICAGO,

PROFESSOR OF SURGERY, CHICAGO CLINICAL SCHOOL; ADJUNCT PROFESSOR OF

CLINICAL SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL

COLLEGE OF THE UNIVERSITY OF ILLINOIS; ATTENDING SUR-

GEON TO COOK COUNTY HOSPITAL AND THE WEST

SIDE HOSPITAL.

IN suture of the abdominal wall after laparotomy, the idealmethod of approximation is that of layer to layer apposition,uniting peritoneum to peritoneum, fascia to fascia, and skinto skin by independent planes of suture.

The ideal suture material is one that can be renderedsterile by boiling in water that will remain sterile while in thetissues, and that will cease to exist in the tissues when- healingis complete and its function has been accomplished.

These indications are not fulfilled by absorbable sutures,of which catgut is the type, for the reason that this materialis of animal origin, already infected with germs, the steriliza-tion of which is difficult and uncertain, and cannot be accom-plished by prolonged boiling in water without disintegrationof the suture.

Absorbable sutures eventually break down and pulpify,liberating any imprisoned germs and making a line of culturematerial, a nidus for pyogenic germs, either local in the catgutorhbrQught to it by the blood current. Many times late infec-tion of a wound after primary union has occurred is due to thisaction of catgut.

'Read before the Mississippi Valley Medical Association, SeptemberI3, I90I.

Vol. XXXV, No. 3, 1902. 297

CHARLES DAVISON.

Permanent buried sutures, the type of which is the twistedsilver wire, are not the ideal sutures.

After healing has occurred and their function has ceased,they become foreign bodies, and either are encysted in thetissues or are surrounded by granulation tissue, and are gradu-ally extruded from the tissues months or years after the opera-tion.

I wish to present the method of closure of abdominalsections that I am using in routine work.

The wounds are closed by suturing each layer with a con-tinuous silkworm-gut suture, the ends of which are left outat the angles of the wound to be removed by traction whenhealing is complete.

The suture in the strongest layer is tied in position at eachend in the layer with knots that can be unlocked by traction onthe exposed ends when the stitch is to be removed.

The closure of the peritoneum in a median laparotomy isillustrated by Fig. i. The edges of the peritoneum are caughtwith forceps and held up away from the intestines by an assist-ant, and the peritoneum is closed by a continuous herring-bonesuture of silkworm gut.

When the opening in the peritoneum is closed, the sutureis shirred to take up all of the slack and to lessen the lengthof the wound, and the ends are left hanging out of the anglesof the wound.

The silkworm gut is kinked in such a manner that it bindsitself in the peritoneum and does not slip or pull apart; but bvthe end of a week, when the suture is removed, the elasticity ofthe silkworm gut has made the suture perfectly straight, andhas brought the perforations in the peritoneum into a straightline, making a track around the stitch by pressure necrosis, sothat it is very easy to remove by traction.

In removing this suture, the patient relaxes the abdominalwall by elevation of the thighs and shoulders; one end of thestitch is cut short, the other end is grasped in an artery-forcepsprotected by a bit of gauze and wound up close to the skin, andtraction is made on the forceps like the handle to a corkscrew.

298

s. . .. . ... .. .. . ........ ..!~~~~~~~~ .... ..

*~ ~ ~~ ~~~~~~~~~~~~~~.

.. :; .. .. :~~~~~~~~~~~~~.... ...... . :

. :* ..!.:.:..' :',0...

...4 S .FXSX..

FIG. i.-Suture of peritoneum.

FIG. 2.-Suture of linea alba, tied in position.

FIG. 3.-Diagram of knot.

m:!:::~'.... ....

:.:: ::::.: .:.: :.::'.i:':i:

FIG. 4.-Suture of the superficial layer.

FIG. 5.-Suture of the sac.

SUTURE OF THE ABDOMINAL WALL.

For identification at removal, this suture may be coloredblack with silver nitrate, blue with an alcoholic solution ofmethylene blue, or the ends knotted to correspond.

The closure of the lineal alba in a median laparotomy isillustrated by Fig. 2. This is the strong layer of the abdominalwall, and if the tissues are fastened securely there can be nospreading of the wound. For this suture coarse selectedSpanish silkworm gut thirteen inches long without flaw ordefect is used.

A small reverse bow-knot (a diagram of which tied andloose is shown in Fig. 3) is tied four or five inches from theend of the strand. The edges of the fascia are caught withforceps and held up by an assistant. The suture is introducedin a firm place in the fascia back from the edge of wound anddrawn tightly up to the knot, and the wound is closed by thecontinuous herring-bone suture. At the last stitch the sutureis shirred up tightly, grasped by a smooth pointed dissectingforceps at its exit from the fascia, and another reverse bow-knot tied below the point of the forceps. With practice thiscan be done without a particle of slack being left in the suture,It can be tied in this manner as closely as in the ordinarymethod of tying a continuous suture. This layer beingsecurely fastened takes all of the tension from the other layers.The ends are allowed to hang out at the angles of the wound.This suture is removed in two or more weeks. Simultaneoustraction on the free ends unties the knots, when the suture isremoved in the same manner as the peritoneal suture.

The skin is closed by the Halstead subcuticular stitch(Fig. 4) of silkworm gut colored red for identification byalcoholic solution of carbol-fuchsin.

These sutures -act- as capillary drains from each layer.If there are bleeding points which pressure or torsion do notcontrol, they may be constricted by loops of the nearest suturewithout making a knot.

This method of suture can be used in appendectomy orany laparotomy in which there is no provision for drainageand in which the incision is in a straight line.

299

CHARLES DAVISON.

The same method of suture can be applied to any of thestandard operations for the radical cure of inguinal hernia.

The sac is closed by a continuous mattress suture (Fig. 5)of silkworm gut, the ends'shirred up, making a sort of doublepurse-string suture. The lower end'is marked by a knot foridentification, and- the ends are tied together and brought outof the upper angle of the wound. This suture is removed atthe end of a week by pulling up the'lower strand and cuttingit short, and then drawing out the upper fragment.

In the 'operation for'hernia in'which Poupart's ligamentis imbricated over the conjoined tendon behind' the cord, whichi usually do, a simple continuous basting stitch (Fig. 6) tiedat either end is used. The suture with the knot tied at oneend is passed through'Poupart's ligament about one centimetrefrom its free edge, close' to the cord, penetrating the liga-ment from the outside' and emerging from its internal'sur-face.

The suture is next carried across the wound behind thecord and penetrates the conjoined tendon at the same level anddistance from its edge, emerging on the peritoneal side of theconjoined-tendon. The suture is -then returned through thesame tissues in the opposite direction, one centimetre below thefirst perforation, completing one unit of the continuous bastingor sailor-stitch, which, when completed, is tied in position withthe knot shown in detail in Fig. 3, and'the free ends are allowedto extend out at 'the angles of the wound. (Fig. 7.) This isthe strong layer, and when sutured firmly takes the tensionfrom the'other layers.

- The fascia of the.:external'oblique muscle is sutured to theshelving edge of Poupart's ligament over'the cord with a con-tinuous'herring-bone' stitch (Fig. 8) of black or blue silkwormgut, the ends projecting from'the angles of the wound withoutbeing tied.

The skin layer is closed by the subcuticular suture of redsilkworm gut already'described. (Fig. 4.)

The suturing of Poupart's ligament to the conjoined ten-don by edge to edge apposition, as in the typical Bassini opera-

300

FIG. 6.-Basting suture uniting Poupart's ligament to conjoined tendon inthe imbricating operation for hernia.

................................ ~~~........

FIG. 7.-Basting suture uniting Poupart's ligament to conjoined tendontied in position.

-30

f-

1 ..

FIG. 8.-Suture of fascia of external oblique muscle to Poupart's ligamentover the cord by continuous herring-bone suture.

:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.

aO_N

FIG. 9.-Suture of Poupart's ligament to conjoined tendon by continuousherring-bone suture, producing edge to edge apposition as in Bassini'soperation.

FIG. io.-Suture of Poupart's ligament to conjoined tendon by continuousmattress suture, producing the same apposition of tissue as in Hal-stead's operation.

SUTURE OF THE ABDOMINAL WALL.

tion, can be accomplished by a continuous herring-bone suture(Fig. 9) of silkworm gut tied at each end in the ligament withthe reverse bow-knot.

The suturing of Poupart's ligament to the conjoined ten-don by a continuous mattress suture (Fig. io) of silkwormgut tied at either end in the ligament produces the same appo-sition of tissues as in the Halstead operation with the buriedinterrupted mattress suture of silver wire.

In general, the advantages of this method of sutureare:

(i) Certainty that all suture or ligature material placedin the wound has been made sterile by boiling in water.

(2) Accurate layer approximation of tissue.(3) Removal of the buried sutures when healing is com-

plete.(4) Capillary drainage from each layer.(5) Safety of intestines from injury during the applica-

tion of the sutures.(6) Rapidity of application.(7) Minimum line of irritation on the peritoneal surface

and consequent adhesions to the viscera.(8) Slight scar in the skin, there being no perforation of

the skin by sutures.(g) All of the advantages of a permanent buried suture

without the danger of future irritation and extrusion of theknot.

(io) The advantages of an absorbable suture withoutthe danger of sepsis from the suture, and without producing anidus for septic germs from the blood current during absorp-tion.

In the seven months following January 3, I9OI, the dateof the initial use of the knot, I have used this method in elevenmedian laparotomies, in eight appendectomies, in four ventralherniotomies, and in seventeen inguinal herniotomies, all of myabdominal operations that were closed without drainage, andobtained sterile primary union in every case. The most recent

30I

302 CHARLES DAVISON.

of these cases being now six weeks from operation and safefrom suppuration.

The claim for originality which is maintained is not inthe use of a longitudinal suture, but in the tightly and securelytying of a buried longitudinal suture which can be easily re-moved when healing is complete.